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Phumorol~ fo r
t~lu-n
tion pr... ntrd in this book. Th. autbors, rdito ... and tho publimer, boweYfT, gnnOl a"ept any r(~lIIjbilily for erron or
omi .. ions or for consequ.n= from application of tho information in this book and make no warranty, tlJ'",ssor implird, with
r~spect to its contenu.
Th. authorsand publish" ha", ,,,,,rtrd eYfiy dfon to ,nsn",
that druSs..!tions and do,,&,o .. t forth in this text a", in accord
with currrnt =mmendations and procti.. at tim. of publication. How"".r, in vi.w of ongoing ",..aRCh, changes in go",rnm.nt "sulations, and the constant flow of information ",lating to
drug thtrapyand rtactions. th. re-ddHis ut&M 10 ,hKk Ih~ pad:.a&, inserts of all drugs for any change in indications or do ..&, and
for addrd warning and precautions. This is partkularlyimportant
wh.n tho =mm,nd,d ag.nt is a now and/or infn<J.u.ndy ,mployed drug.
"'""4'"
Coppight C lOll. 2006, 2005 by Poarson Ec1ucatiofL Inc., UI'P"" s..Ldle Riv<r. New In..,. 07~sa.AD rights , ... r...d.. Printod io
th. Unit"! Stat.. of """'ie.. This publication is p'otKf1 byCopyright and p<rrni"'oo should be obtai""] hom th. pubUoher
prim to my prolu'bittd "Production, stong. in 0 mrmlsy>ttm, OJ traosmi .. ion in any fmm or by any .,...0., d.,ctroDic
....m.mco1, photocoPfini, re>rdio,. OJ lilm<i. ... For informatioo reprdiog porm;"ion(o). writ< to: Righ", mel J>.rmissioos
~ a n .... nt.
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Brief Conupts: ). lWrooi/Pboto Rrsnrcbon, [nc.; Titl, p.I!' top: lIioModiullSbuttontod:: v: ~ Bavosi/Photo R....um.ro, In<.:
vi: [. Ba"""i1Photo Ro ...,che... lnc.: >ii: ). Ba..."ifPhoto R< ...
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GmhH/Alamy; IIiii : ~ Photo Libury/Alamy: p. 53: ). B.",oi/Photo Rrsnrm.... [nc.; p. 54: J. Bavos:i/Photo R.....m..ro,
In<:.: p. 6): [. Bavosi/Photo Ro ...m.....lnc.: p. 76: ). Ilavosi/Photo R...arrnu [oc.: p.M: J. Ila>oi/Pbo", Rrsnrch<-r .. [nc.:
p.94: [. Bavosi/Photo Ro ...,m. .... Inc.; p. 103: ). Ba",.i/Pho", Rrooa"b.. .. [nc.: p. 109: ~ Photo Libury/Abm.y: p. 115:
). B.",oi/Pho", Rrsearcbon, [nc.: p. 4.(5: BioModical/.I3>unmtodc: p. 6: BioM1icalJSbut"",ock: p. 464: BioMecl.icall
Shutt.",,,,,,,; p. 478:: BioModical/Slm"",stod: p. 506: lIioModicallShutt .... t"""; p. 526: BioMtdkal/Slmt.....""": p. 547:
lIioM..!"teallSbut"''''''''': p. :il l: Doc:Cbcd Modica! s.r.x.-. GmbH/Ala..".: p. :il2: Doc:Cbcd Modica! s.r.x.-. GmbH/AI.my;
p.589: Do:I..d: M<cI.ico1 s.ni= GmbH/Alamy; p. 655: ~ Photo Libnry/Alamy: p. 656: Sc;"n Photo Librnry/Alamy;
p. 678: ~ Photo Libr orr/Aiamy; p. 694: .x;.,n Photo Library/Alamy: p. 715: ~ Photo LibraryiAlamy.
.m.rs.
PEARSON
_ . pearsonhlglH!ri!d.com
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ISBN lJ: 978_0 lJ_508981 1
O
lJ_508981 6
ISBN IO:
Michael Patrick Adams, PhD, is an acoompJished educator, author, and national speaker. The
Na tional Institu te for Staff and Organizational Development in Austin, Texas, named Or.
Adams a Master Teacher. He has published two other textbooks with Pearson Publishing: Core
Concepn in Pharmacology and PharmarolOjy: COImlcrums to Nursing Practict.
Dr. Adams obtained his Master's degree in Pharmacology from Michigan Slate University
and his Doctorate in Education at the University of South Florida. Dr. Adams was on the faculty of Lansing Community College and 51. Pe tf."rsburg College, and w;u IXan of Health Programs at Pasco- H ernando Community College fo r IS years. He is currently Professor of
Biological Sciences at Pasl-Hernando Community College.
I dedicate this book to nursing educators, who contribute every day to maki"g the wurld a ~tter
leland Norman Holland,Jr., PhD (Norm) over 20 years ago started ou t like many
scientists, plarming for a career in basic s.:-ienuo resean;h. He was quickly drawn to
the field of teaching in higher medica.! educatio n, where he has spent most of his
career since thelL Among the areas where he has been particularly effective are
preparatory programs in nursing, medkine, dentistry, pharmacy, and allied health.
Dr. Holland is both an affiliate and supporter of nursing eduation nat ionw ide. He
brings to the profession a depth of knowledge in biology, chemistry, and medially
related subjects such as microbiology, biologial chemistry, and phannacology. Dr.
Holland's doo:toral degree is in medical pharmawlogy, He is very much dedkated
to the sua:essof students and their preparation for work~Jife readiness. He mntin~
ues to motiv:ate students in the lifelong pursui t oflearning.
I wOllld Ii~ to thank rhewillful rncollmgt'mem of Farrell and Norma Jean Stalcllp.1 dedicate this book ro my beloved wife, Knrr!1l.
and my three wonderful childreH, Alatmdria Noelle, my double-deuce dttugiller, Caleb James, my Humber-one SO Il, arid Joshua
Na,haaie~ my nllmber three "O.~
-LNH
NURSE CONTRIBUTOR
is the Assistant Dean for Undergraduate Nursing and an Assis tant Professor in the School of
Nursing, Collese of Health and Human Servires at George Mason University where she teaches undergraduate courses in
pharmacology and pathophysiology. Her current research interests focus on improving learning for students at-risk for academic difficulties, outcomes-based education, effective educational mCKlels using computer-based learning, and servicebased learning. She has also publ ished articles on the ethial needs of at-risk students,
She is a member of Sigma Thet~ Tau - Epsilon Zeta chapte r, Alpha Chi, the National A.ssoci~tion for Developmental
Educa tion, Na tion al College Learning Center Associa tion. and the College Reading and Learning Association. At Grorge
Mason University, she sel'Vl.'S on the General EduOition Committee and the Distance Education Council.
To my daughter, Joy, an extraordinary, resilient yvung woman. And ill memory of my son, Keith, the brawst and happiest soul I
know.
-CQU
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SUPPLEMENT CONTRIBUTORS
Rosem ary Ba kasa, RN, MSN, PhD
Bry"nt and Stratton CollegeEasdab: Campul
Easdak<:, Ohio
Imtruaar. Rnouru M.,nual
PuwtrAlin"
Ma r ge G ing r ich , RN, MSN
Harrisburg Area Community College
Harrisburg, ~nnsylvania
MyNursinglAb
REVIEWERS
Joy Ach e- Reed , RN , MSN
Indiana Waley,,," Univo:rsity
Marion, Indiana
Ene li a O. Alfred, RN, BSN, MA, MEd
Kmt State UniV<:rsi ty, TUKaTaW'iU
N<:w Philadelphia, Ohio
Rosem a r y Ba bsa, RN, MSN, PhD
Bryant and Stratton CollegeEastlili Campus
Eastlake, Ohio
"
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~ights, suggestions,
t o ra McGuire, RN, MS
Joliet Junior Colleg<:
IoIi<:l , llIinois
Il e n e Bone, RN, MS
Gat<:WaY Community CoIleg<:
Phoenix, Arizona
Ch ri ~tin a
eNE
North Idaho CoUeg ..
Coeur d'A1el~, Idaho
La uri e Simm o n s, BSN, MSN, MEd
Kirkwood Community College
Cedar Rapids, Iowa
Preface
WhenSludl.'nts an.asked which subject in their nllning program is the most challenging, pharmacology always appears
ncarlhe top orlhe list. Thesludyof pharmacology demands
that students apply knowledge from a wide variety of the
natural and applied sciences. Successfully predicting drug
action requires a thorough knowledge of anatomy. physiology, chemistry, and pathology as WI.'Il as the social sciences
of psychology and sociology. Not properly applying pharmacology can result in immediate and direct harm to the
palient; thus, the Slakes in learning the subject are high.
Pharmacology ClInnal De made easy, but it can be made
understandable, if the proper cormt'Clions are made to
knowledge learned in these other disciplines. The vast majority of drugs in clinical pr.l("tice are prescribed for spedfic
diseases, yet many pharmacology twbooks fail 10 recognize
the complex interrelationships between pharmacology and
pathophysiology. When drugs are learned in isolation from
their associated diseases or conditions, students have difficulty connecting phamlacotherapy to therapeutic goals and
patient wellness. The pathophysiology approach of this textbook gives the stlKlent a dearer picture of the importance of
pharmacology to disease, and, ultimately, to patient Qre. The
approach and rationale of this lenbook fOQls on a holistic
perspective to patient care, which clearly shows the benefits
and limitations of phannacotherapy in curing or preventing
illness. Although difficult and challenging. the study of pharmacology is truly a fascinating, lifelong journey.
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vii
ACKNOWLEDGMENTS
When authoring a textbook such as this, a huge number of
dedicaled and lalented professionals are needed 10 bring the
in ilial vision to reality. Kelly Trakalo. Senior Acquisitions
Editor, and Maura Connor, Editor- in-Chief, are responsible
for helping us sculpt the vision for the teJI:1. Our Developmental Edilor. Mich;ael Giac.obbt.supplied the upet"t guid;ance and Indership to keep everyone on I2$k and to be
cul;ain il reached ilS fruition on time. Providing the neussur expertise for our comprem-nsive supplement package
was UUfft"l Sweeney, Editorial Assistant.
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(c~pters) clearly places the drugs in context wi th how they are used
therapeu tically. You can e35ily loca te al l relevant anatomy, physiology,
pathophysiology, and pharmacology in the same chapter in which we
present co mplete information for the drug classifications used to
trea t the disease(s) in each chapter. This organization builds the
connection between phannacology, jtoophysiology, and the
nursing care you learn in your clinical nursing courses.
dja.,tD 1M WIt
DRUGS AT A GLANCE
OIl6ANlCIllWU . .1<1
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PHARMACOTHERAPY ILLUSTRATED
14.1 Th~ ~lwlar Actlwotlng S~.m and Rebt. d RRgIon.1n the Brain ant Imporbnt
ANal of Focus for Drugs Uslto r rut A.... '-ty ~ Anx'-tyRl latad Symptoms
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Mechanism of Action anim3wd tutorials featured in MyNursking Kit clearly ~ow drug
action at the molecular, tissue, OI"8an, and system II'YeIs.. ....
M ECHANI SM OF A CTION A NIMATI ONS
Acetiminophell
Acyck:Nil
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Digoxin
Oiphen/ty!;kamine
Dopamine
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"
19
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Ch.23
(h.29
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(ILJS
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Venlafaxine
eh.34
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Additional Nursing Process Focus charts are available on MyNu r5in gKit .
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io
The tools at the end of each chapter and on the ao mpanyi ng media resources help yo u test
your understanding of the drugs and nursing care presen ted in th at chapter. Using these
tools will help )U U su eoo in your pharmacology course, in the di ni cal set ting, on the
NCLEXRN", and ultinlauly in professional nursing practice.
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Core Concepts
in Pharmacology
CHAPTER 1
CHAPTER 1
CHAPTER J
CHAPTER4
Pharmacokinetics
CHAPTER 5
Pharmacodynamics
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Introduction to
Pharmacology: Drug
Regulation and Approval
LEARNING OUTCOMES
Aher reading this chapter, the student should be oble to:
6. Identify key U.S. drug regulations that have ensured the safety and
efficacy of medications.
7. Discuss the role of the u.s. Food and Drug Administration (FDA) in the
drug approval process.
8. Explain the four stages of approval for therapeutic and biologic drugs.
9. Discuss how the FDA has increased the speed with which new drugs
reach consume rs.
, O. Identify the nurse's role in the drug approval process.
KEY TERMS
biologjn (X1gt4
dinical investigation fUJI6
diniGlI phal~ trials JX!gt6
complementary and alternative therapies
"",
drug
{!all 4
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mfdication
NDArnifw
PQl}f4
plqtl
pharmacology ptTJt J
pharmacopoeia ftlf/l' 4
pharmacotherapy ptTJt4
postmarbting surveillu ce ~7
predinkal inwst igation pq;16
therapeutics (!11;!4
out of
si~
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~od "PPIO'o'~t
In the 20th century, the pace of Change in all areas of medicine continued exponentially. Pharmacologists no longer
needed to rely on the slow, laborious process of isolating active agents from Karce natural products; they could synthesize drugs in the Laboratory. Hundredsof new drugs muld be
synthesized and tested in a relati'"ely shor t time. More impor_
tantly. it became possible 10 uoo.erstand now drogs produced
their effects,down to their molecular mechanism of act ion .
The current practice of phannacology is extremely com
plex and far advanced compared with its earl y, primitive his_
tory. Nurses who consult with pharmacists in the use of
pharmacologic substances aoo. other health professionals
who practice it must never forget its eolrly roots: the applica.
tion of products to relieve human suffering. Whether a substance is extracted from the Pacific yew tree, isolated from a
fungus, or created totaDy in a laboratory, the central pur_
pose of phannacology is to focus on the patient and to im
prove the quality of life.
!z
i
o
"t
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(MhA) was founded. From 1852 to 1975, two major compendia maintained drug standards in the Un ited Stat es, the
U.s. Phurmacopoeiu and the Nutionul Formulary (NF) established by the APhA. All drug products wne covered in
the USP; pharmaceutical in gredients were covered in the
NF. In 1975. the two entities merged into a singl e publi catiOll , th e U.S. Pharmilco/'Mill- Niltionill Formlda,y ( USPNF) . Th e current document of about 2,400 pages contains
3,777 drug monog raphs in ]64 chapters. Official monographs and interim revision announcements for the USPNF are published regularly, with the full bound venion
printed every 5 years. Today, the USP label can be found on
many medications verifying the purity and e.xact amo unts
of ingredients found within the container. Sample labels a re
illU5trated in ~ Figure 1.\.
In the early 1900s, the United States began todevdop and
enforce tougher d r ug legislation to protect the publ ic. In
19UZ, the BiolOSlcS Control Act helped to standardI ze the
quality of serums and other blood- related products. The
Pure Food and DrugAct of]906 gave the government power
to control the labeling of medicines. In 1912, the Sherley
Amendment prohibited the sale of drugs labeled with false
therapeutic claims that were intended to defr:lUd the con sumer. In 1938, Co ngress passed the Food, Drug, and Cosmetic Act. This was the first law preventing the sale of drugs
that had not been thoroughly tested before marketing. Later
amendmen ts to th is law required drug companies to prove
the safet y and effiOKY of any drug before it could be sold
within the United SUtes. In reacliOll to the rising popularity
of dietary supplements, Congress passed the Dietary Supplement Health and Education Act of 1994 in an attempt to
COlIIroI misleading indu.m y daims. A brief timdine of ma jor events in U.S. drug regulation is shown in ~ Figure 1.2.
_0___
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"
PHARMFACTS
......
thtmid-199Oi.
urjt
,....,.
A gtOUp 01 physicians Hlllbliahed the fim ce>rnpNhansi"" pubfication cI drug standards calfed the U.S. P "'rmecopeioo
t l62
A group of pharmscists b.r.dotd, nationaf p""-icnal society called !he A .... ricen P ........... ulic. AHOC_ ion (APIIA).
The APhA then Hlllblished the Nstion.l l Formu ltory (NFl, e standardized publiClltion fOCUlling on phrirmroceuliClll
ingredients. The USPconIi.-.-l to catalogue all drug MlBIed substanou and ptOduc:ta.
1162
This was the beginning 01 the Flde ... 1Bureau crI Chemistry. Istablishod !6Iderthe lidrrinml"lllicn 01 PNlsideni Uncaln. CNer
Ih' Y""'" and with added dutiH. it gl"lldUllily became the Food and Drug Adminilllnltion (FDA).
11112
Congreas!>'lssed the Biologics Conlrot Ac t tocontrcl!he qUlllity of Hnms and otharbfoodmlalld producta.
tlOl
The PUIS Food a nd Drug Ac t ga1l8 the gllYllmmen\ powe' tooontrol the Itobeing 01 medicines.
181 2
The S ...rtey A.... ndment made medici""" ... te, by prohibiting the sal, 01 drugs lab<lled with false thempevticclaimr;.
1131
Coogre55 p1155ed the Food, Drug. and Coe meti c .... ct.lt W!III the firm law prevenling the lTliIIketing 01 drug' not thoroughly
Tested. TWs law now provides lor the reqliremen1 thel drug
"",51 s ubm~ a New Drug AppIk:lltion (NDA) to the
FDA prior to marf<eting a new drug.
1144
Congraas passed the Publ ic Hedh Se rvice Act. CCM!Iring many health issues inclo.rding bioIogiCIII ptOdllCla and the oonlrot
oIlXlITWTIIInicabie diseases.
11 75
The U.s. PhllfmllCOfNl's and National Fo<mulsry a mco.rr><:e<l their union. The USP-NF became a single standardized
publiClltion.
lilli
Congreas pas.sed the Childhood Vaccine Ac t. 11 owthorized lhe FDA to acquire information ebout pllliento la king vaccines, to
recall biologics. a nd to """"""",nd civit penalti_ if guidelines regarding biologic""" wore not foIlowod.
11188
The FDA we officirtly Hlablished as a n agoncy 01 the U.S. Deputment of Hedh a nd Hume n Servicea.
10112
Congraas p assed the Presc ription Drug Us er Fee Act. tt required thai """!I8neric drug and biologic manufacturers pay Ieee
to be used tor impra.oement. in the drug review prooesa.
10114
Congress!>'ls.sed lhe Diete ry Suppfement H_ lth a nd Educ ation Act thai ,e qui,,"s clear ta beii"9 of dietary supplemenls.
This act giV'llS lhe FDA the power to """""'" supplements that CIIuse a significant risk 10 lhe pWtic.
10117
The FDA Modernizat ion Act reaulhorized Ihe Pmsaiplion Drug User Fee Act. The eet rep"""",led the la'9"st ",form effort
oIlhe drug review process sillC8 t 938.
2002
""""anI_
The Biote rro riam Act irnpleme nled guideli ..... for registralion 01 oolected loxins !hat oculd p""" a threat to human. animal,
Act r",,"YftKl, ~ ..... ,,<loo~, u,,.j (uoslfi""..<lI"lioi u1i"" tu all"", lur ..<l~iliu"..1"""'I"<tI, .. ,....... ,"" .. _ uI
oow drugs a nd medical products. Thia eldended the reforms i~ from 1997. The FDA. Cr~ ice l PIIth In~iati Yl was a
part 01 !his re!O<ITI.
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ways reflect the way a human responds, preclinical investigation results are always inconclusive. Animal testing may
overestimate or underestimate the actual risk to humans.
In January2007, the FDA restated its concern that a number of innovative and critical medical products had decreased sinc"" the 19905. The FDA's Critia l Path InitiatiYl! was an
effort to modernize the sciences to enhance the use of bioinformation to improve the "safety, effectiveness, and manu facrurability of candidate medical products." Listed areas of
improvement haw been the fields of genomics and proteonomics, imaging, and bioinformatics.
CliniGlI inYl!stigation, the second stage of drug testing, takes
place in three different stages termed dink. l phaSl' trials. Clinical phase trials are the longest part of the drug approval
process. Clinical pharmacologists first perform tests on
healthy volunteers to determine proper dosage and to as-
CNplfll
Pr"",linical
Inves tigation
(Stage 1)
NOli. Review
(Stage 3)
Rar>gfI: 1-3
~,
-,
Clinicel
Investigation
(Stage 2)
,N'
Avemge: 18
FIMge:2
'
~ ...
i""
.....
Postmarketing
Studies
(Stage 4)
Adwf'&8
Reaction
Reporting
"
I.,;tial
Synthesis
'ilO~
Survey",
Sampli"9'
Tasting
Animal
Testing
Inspections
II
3DDay
FDA T"""
c::::J
NDA
IndustryT""" c:::::::::J
Submitted
Figure 1.3 A new drug development IImellne, with the four pha5l's of dlug approval
Safety Review
~pr""rs
tn he effective
~nn
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urjt 1
L IFESPAN CONSIDERATIONS
Th~ Question: AIt the,t
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In the early 1990s, owing to pressures from organized consumer groups and various drug manufacturers,gowmmental officials began to plan how to speed up the drug review
process. Reasons identified for the delay in the FDA drugapproval procer.s included outdated guidelines, poor communication,and in'lufficient staff to handle the workload.
In 1992, FDA officials, members of Congress, and representatives from pharmaceutic:al companies negotiated the
Prescription Drug User FeeActon a 5-yeartrial basis. Thisact
required drug and biologic manufacturers to provide yearly
product user fees. Thisadded income allowed the FDA to hire
more employees and to restructure its org;mization to more
efficiently handle the processing of a greater number of drug
applications. The result of restructuring was a resoWlding
success. From 1992 to 1996, the FDA approved double the
number of drugs while cutting some review times by as much
as half. In 1997, the FDA ModemizationAct reauthorized the
Prescription Drug User Fee Act. Nearly 700 emplo~es were
added to the FDA's drug and biologics program, and more
PHARMFACTS
Time Length for New Drug Approvals
It uk6 about II YUB of ft'Itmh and deveIopmenl btfore a drug is
CNpltl t
TABLE 1.1
Step 1
Step 2
Step 3
Step4
Step S
Step 6
Therapeutic Products Directornte (TPD) authorizes marketing of a pharmaceutical drug or medical device, once a
manufacturer presents sufficient scientific evidence of the
product's safety, efficacy, and quality as required by the
Canadian Food and DrugsAct and Regul.1lions. The Biologics ~nd Cenetic Ther~pie.
Director~te
(BCTD) ",suhtes bi _
JILCl
_ ____________________________________________________________________________________________
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the oorresponding numbered section
within the chapter. If any of these points are not clear, refer 10 the numbered section within the chapter for review.
1.1
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10
1.5
1.6
1.9 Once critidzed (o r being 100 slow, the FDA has stream
lined the process to get new drugs to market morequidly.
1.10 Drugstandards also ensure the effectiveness and safety of
drugs for Canadlan consumers.
1.'1 Nurses may partidpate in several phases of the drug approval process but will have the most frequent opportunities during Phase IV, posll1lllrketing surveillance.
EXPLOflE
M'jtiu~iI!;l(iI:
......"'I.a.gk it.cam .
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LEARNING OUTCOMES
After rmding this chapt~ the student should be abk to:
1 . Explain the basis for placing drugs into therapeutic and pharmacologic
dasses.
2. Discuss the prototype IIpprollch to drug cI.nslflclIllon.
KEY TERMS
biOilvailability plgt14
chtmicillnamr M ill
combination drug {XiIj111
controll~dllJbstan~ ~14
d~pfndfn'f pu;t 14
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g~neri(nam~ fll9t'1J
sd1~duled
drugs
{!alt 14
1]
U5e.
This chapter
by drug
schedules.
Therapeutic Usefuln~s
_........
Therapeuttc CllIssJtlcaaon
M11ial191NOO
~lbIddloltlltfOl
Mlli/!)'perIipidmIiG
anI~
M1~
n_iI9N
Riln.jnah
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lAHLEll
MKhiilntsm of Al::UOIl
Phafmacologk da5s1f1callon
IowfI'I ~ 'IIJUn~
~k
block! hmrmaI.ctiviIy
angicrlmsill-{OlWff\jng !'IIl)'m~
inhibitor
.1iRntr9ic:maqonilt
dilatrsptrip/lfr.lllbldv~
vl\odilalDr
O\.apur I
which is sometimes helpful in predicting asubstance's physical and chemical properties, Although chemical names
convey a clear and concise meaning about the nature of a
drug, tln,y are
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TABLE 2 3
...
13
Generic SubstancE'
8rand Names
ispiin
ibuprofeon
""""
T""",,
14
linK I
PHARMfAcrS
."tlrKtM.
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PHARMFAcr S
~'-IIlCRth.Jn2.~
'"
,
y
Potential for
"'"~
Potential
PotenUal for
Physical
Dependency
Dependency
Examples
Therapeutic Use
hight\l
high
high
high
...
rr.odtr,,~
h"
h"
h"
moderat~
-.
....,
....,
~hoIoglc
_",_d.",[P.'.~;",.
IMthador'ot, Jnd IMlhamphnamilll'
anabolic 11ffiids,(lHI~ineand h)'ltocodone
w~h aspiril or Tylmol, and !OIIII' barbiturate
1-
dextropropolyphtnt,pmtizocine,
mtprObarnat~ diiztpam, ilpruolam
1-
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}
Ultd thtrJpNtiul1 with ~ion;
!OIIII' rtugs oolongft" UII'd
Control Act and Parts III and IV of the Food and DrugAct.
It further establishes eight schedules of controlled substances; two classes of pre<:ursors are covered in one schedule. For a complete listing of drugs, see http://laws.justice
,g"calenlC-J8,8/, The Controlled Drugs and Substances
Act provides broad latitude to the Governor in Council to
amend schedules as determined to be in the best interest of
Canadas citizens. Drugs and substances covered in the
Controlled Drugs and Substances Act correlate with agents
named in three United Nations treaties: the Single Convention on Narcotic Drugs, the Convt'ntion on Psychotropic Substances, and the United Nations Convention
Against Illicit Traffic in Narcotic Drugs and Psychotropic
Substances.
Throughout Canada, both prescription and nonprescription drugs must meet specific criteria for public distribution
and use. Nonprescription drugs are provided according to
guidelines and acts established by the respe<:tive Canadian
provinces. One recent system establishes three general drug
schedules (Table 2.5). Phannacies must monitor those
drugs used specifically to treat self-limiting discomforts
such as cold, flu, and mild gastrointestinal or other symptoms. Other nonprescription drugs may be sold without
monitoring.
Drug Schedule
Drug"'"
,lJ1 pl!saiplioo rtugs
Connollfd !tug!
Narrolic rtugs
All nor-.x~ioo drugs mon~ORd fur~'" by
phalllliOsts
'"
16
UnK I
13
2.4
2.5
Canadian regulations restrict drugs as covered in its foo eral drug control statute: the Canadian Controlled Drugs
and SubstancesAct.
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EXPLORE
~'-----,
="'"
Principles of Drug
Administration
LEARNING OUTCOMES
Aher rtoding this chQpr~ the studtnt should be! able to:
1.
2.
D~rbe the role s and r6pOn sibilities of the nurse regarding drug
administration.
Explain how the five rights of drug administration affect patient safety.
Giw- 5peciflC examples ofhow the nurse can increase patient
complian ce In taking mediclliions.
Inte rpret drug orders that contain a bbreviations.
Compare and contrast the three systems of meawrelTlE'fll used in
3.
4.
5.
6.
phanTIacology.
7. Explain the proper methods of adminh lering enteral, topical, and
parenteral drugs.
8. Compare lind contra st the advantages and disadvllnU!ges of each route
of drug administration.
KEY TERMS
aI~lUctio.
/l4}tla
~is ptl/}t18
apolhwryS)'Slfill {Id'JIll
ASAPortier JXII}tlO
~U~t dff(( pogt 15
buuaI route {II19t 2J
aKIIpIiilD(t p:1qt19
tnlenlroute
ptlJtll
tnlmuoatrd {II1IJtll
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P'9t 19
,.J'
subnrlalleOUl fJIIV 18
ptl9tll
sublingualro~le ptl9tl]
IlIIIiiMdrelease pogt ll
thrft dlKks of chg lIdministratiol
f'JI}t 19
18
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PHARMFACTS
01",1<,1
I.Right patit'nt
2. Right medication
3.llight d""e
Additional rights have been added over the years, depending on particular academic curricula or agency policies. Additions to the original fivt' rights include
considerations such as the right to refuse medication, the
right to receive drug education, the right preparation, and
the right documentation. Ethical and legal considerations
regarding the five rights are discussed in chapter 900.
The thl''(' chub of drug administration that nurses use in conjunction with the five rights help to ensure patien t safety
and drug effectiveness. Traditionally these checks incorporate the following:
1. Checking the drug with the MAR or the medication
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19
Tht FDA "Id !hi- Amt riun Hospital k soc:iation Ir.Kk drug emlB thu occu, in
hNkh {.I~Sf1tings. Till' fiVl' roost OlmmOll G1!M1of rntdiution moB .~:
llKompielr patient inform.tion (e.g., not knowing.bout patitllB'
.llelgie, olher mtditifltl they ale taking. [RI'ious diag~ or lab
=.)
drugs, following the instructions on the label. Patient noncompliance ranges from not taking the medication at all to
taking it at the wrong time or in the wrong manner.
Although the nurse may be extremely conscientious in
applying all the principles of effective drug administration,
these strategies are of little value unless the patient agrees
that the prescribed drug regimen is personally worthwhile.
Before administering the drug, the nurse should use the
nursing process to formulate a personalized care plan that
will best enable the patient to become an active participant
in his or her care (ch.1pter 600 ). This allows the patient to
accept or reject the pharmacologic course of therapy, based
on accurate information that is presented in a manner that
addresses individual learning styles. It is imperative to remember that a responsible, well-informed adult always has
the legal option to refuse to take any medication.
In the plan of care, it is important to address essential information that the p.1tient must know regarding the prescribed medications. This includes factors such as the name
of the drug, why it has been ordered,expected drug actions,
L IFESPAN CONSIDERATIONS
20
_....TA8lf 3.1
..~-
...
.......
up
u p!U1e
'"
...
~~
horhr
"
"
"'
00
PM
PRH
i6 dtsimllilSlllfard
twiceperlWy
'mp
.
.......
mtrilmUKUlar
~
~-
"1Im~~
"
q2h
,Ih
MI)' 4 hoo.n
q6h
MIl6hoo.n(t'ltn)
..
,,~
....
SW
[r'ltn)
...
Ml)'llholn
1nrneIia1tlr, .. ona
.-
nw, InIlitUlr r", Safr Mtdul ~es rtcOmmtllCb thit cllt fdlowing
abbrtilticllI be _oidrd beuuIe the)' Ql'lleld to medication trrOI1: cr. imcrld
lilt "t'ltry"; qh:inllrld lilt "hou"Y' or"MI)' hoII'"; qd: inllNd lilt 'daily" or
"emy day": qhs:inlleld lIIt'n~Uy";qod:lnIlNd u~"emy other day:For
o1htr rommrndllions, 1ft the otIidil Joint Corrmissioo"Do Not Ust li5f:
P HARMFACTS
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ca n be obtai ned from th e pharmacy and administered immediately. The timebetwn writi ng the order and admin _
istering the drug should bf 5 minutes or less. Although not
as urgent , an ASAP onIt. (as soon as possible) should be
available for administration to the patient within 30 min_
utes of the wrill~n o rdn.
The single onItr is for a drug that is to be given only onct,
and at a specific time, sud! as a preoper:r.tive order. A PRNor
d~r (Latin: pro re IIOrD ) is ad ministered as reqlliredby the pa _
tient's condition. The nurse makes the judgment, based on
patient assessment,as 10 when such a medication is to bead_
ministered. Orders not written ~s STAT, ASAP, NOW, or
PRN are called routint 0Idtn.. These are usually carried OUI
within 2 hours of the time the o rder is written by the physi_
cian. A ~0I'dft is wr itten in advance of a situation thai
is to be carried out under specific circumstances. An exam_
ple of a standing order is a set o f postoperative PRN pre_
scriptions that art written for all patienl5 who have
undergone a specific surgical procedure. A common standing order for patients who have had a tonsillectomy is
~Tylenol elixir 325 mg PO every 6 hours PRN sore throat."
Because of the legal implications of putting all patients into
a single treatment category, standing orders are no longer
pennitted in some facilities.
Agency policies dictate that drug orders be reviewed by
the attending physician within specific time frames, usually at least every 7 days. Prescriptions for narcotics and
other scheduled drugs are often automatically discontinued after 72 hours, unless specifically reordered by the
phpician. Automatic ~top order, do not generally apply
when the number of doses or an exact period of time is
specified.
Some medications must be taken at specific times. If a
drug causes stomach upset, it is usually administered with
meals to prevent epigastric pain, nausea, or vomiting. Other
medications should be administered between meals because
food interferes with absorption. Some central nervous system drugs and antihypertell'iives are best administered at
bedtime, because they may cause drowsiness. Sildenafil (Viagra) is unique in that it should be taken 30 to 60 minutes
prior to expected sexual intercourse, to achieve an effective
erection. (Note: Sildenafil is also prescribed to hospitalized
patients for pulmonary hypertension.) The nurse must pay
careful attention to educating patients about the timing of
their medications, to enhance compliance and to increase
the potential for therapeutic success.
Once medications are administered, the nurse must correctlydocwnem that they have been given to the patient and
this documentation is completed only after the medications
have been given, not when they are prepared. It is necessary
to include the drug name, dosage, lime administered, any
assessments, and the nurses signature. If a medication is refused or omitted, this fact must be recorded on the appropriate form within the medical record. It is customary to
document the reason, when possible. Should the patient
voice any concerns or complaints about the medication,
these should also be included.
use the metric system, these older systems are still encountered. In 2005, the Joint Commission (JCAHO), the accrediting organization for health care agencies, added
"apothecary units" to its official "Do Not Use" list. But because not all health care agencies are accredited by JCAHO
and until the metric system totally replaces the other systems, the nurse must recognize dosages based on all three
systems of measurement. Approximate equivalents between
metric, apothecary, and household units of volume and
weight are listed in Table 3.2.
Because Americans are very familiar with the teaspoon,
tablespoon,and cup, it i, important for the nnrse to be able
to convert between the household and metric systems of
measurement. In the hospital,a glass offluid is measured in
milliliters--an 8-oz glass of water is recorded as 240 mL. If
a patient being discharged is ordered to drink 2,400 mL of
fluid per day, the nnrse may instruct the patient to drink 10,
8-oz glasses or 10 cups of fluid per day. Likewise, when a
child is to be given a drug that is administered in elixir
form, the nurse should explain that 5 mL of the drug is approximately the same as I teaspoon. The nurse should en
courage the use of accurate medical dosing devices at
home, such as oral dosing syringes, oral droppers, cylindrical spoons, and medication cups. These are preferred over
the traditional household measuring spoon because they
are more accurate. Eating utensils that are commonly referred to as teaspoons or tablespoons often do not hold the
volume that their names imply. Because of the differences
in volwnes between standard teaspoons, dessert spoons, tablespoons, and "salt spoons,n it is recommended that a
measuring spoon used for cooking be used rather than
. .I
Hou~hold
Metrlc
Apothl!Glry
1.1
lS- 16milims
lH6drops
4-SmL
1 Hliddram
1 INSpoon Of 60 ttops
lH6mL
4nliddrams
lO-11mL
2tablrlpoons
240-250mL
19lalSOfCl4l
SOI.I
1 pint
2gLtsItSOf 1 rups
Il
4 gLtsItS Of 4(UP! Of
I.,
1/6Ograin
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21
1tabirlpOOll Of
l-4twpoOlls
60-64.,
1 grain
300-1151119
Sgrains
I,
I.
"-
15- 16grails
22
UnK 1
CDf~ Concept<;
In Ph.,macology
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A.
titblt~capsul~orliquid
...
Administration Guidelines
I. MIffi that paliffit is alffi aod Iu sibility to swalloloi.
1.
23
1 IUquid, shakr I~ bOIl~ to mil ~ i9ffi~iod mmul! tht dw illo ~ rup 011 ~ ~\'!"I.
s.
- 8.
,
lUblinqual
mftkatioo isswalowtd.
I. MIffi thit patiffit iSaiffi aod luI ibilityto hold ~~oo !lldft"tonqut.
1.
Plac:~
sublinguallabltlllldtftooglll'.
1 10ItrIKI patim: oot 10 dItw or swillow tilt tlbltl, or ~ ~ tabltl around with tooglIt.
0-
s.
I.
M~U that patiffit isal~rI aod lui abilityto hold ~~oo btI'IIftO Iiii' I1Jms aod tfNo dltrl.
.. 1011100
s.
,
D.
na~stric:iodga5l1ollOmy
1. If 1Oid.<rIIIh find, inlo powdtr and mix thoroughly with allml30 mLofWilnn wal~ !Il~1 dislOl"lfd.
1 M~llald vffify lUbe pIi(emtOt.
s.
,
,.
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to move the drug with the tongue, nor to eat or drink anything until the medication has completely dissolved. The
sublingual mucosa is not suitable for extended-release formulations because it is a relatively small area and is constantly being bathed by a substantial amolUlt of saliva.
Table J .J (section B) and ,.. Figure 3.1a present important
points regarding sublingual drug administr:ltion.
To administer by the buccal rout~, the tablet or capsule is
placed in theor:ll CllVity between the gum and the cheek. The
patient must be instructed not to manipulate the medication
with the tongue; otherwise, it oould get displaced to the sublingual area, where it would be more rapidly absorbed, or to
the back of the throat, where it could be swallowed. The buccal mucosa is less permeable to most medications than the
sublingual area, providing for slower absorption. The buccal
route is preferred over the sublingual route for sustainedrelease delivery because o f the greater mucosal surface area
of the former. Drugs formulated for buccal administration
24
'b' ...._____ _
,.)
~
ADMINISTRATION
Patients with a nasogastri, tube or enteral feeding
m~ha
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01",1<,3
Prlndple<oION9Admlnlnr. tIon
25
..;;,9,
~1w.
,
(.)
(b)
FlgureJ.2 Transdermal patch administration: (a) protective coaling removed from palch;(b) patch Immediately applied to dean,
dry, halrlesi skin and labeled with date, time, and Inilials
Source: PeaWfi fiiKarfooJPHco/~.
sorbed very slowly, and amounts reaching the general circulation are minimal.
Some drugs are given topically 10 provide for slow release
and absorption of the drug in the general circulation. These
The otic route is used to treat local conditions of the ear, indud.ing infections and soft blockages of the aud.itory canal.
Otic medications include eardrops and irrigations, which
are usually ordered for cleaning purposes. Administration
to infants and young children must be perfonned carefully
to avoid injury to sensitive structures of the ear. ~ Figure 3.4
and Table 3.4 (section C) present key points in administering otic medications.
NASAL ADMINISTRATION
The nasal route is used for both local and systemic drug administration. The nasal mucosa provides an exceUent absorptive surface for certain medications. Advantages of this
route include ease of use and avoidance of the first -pass effect and digestive enzymes. Nasal spray formulations of corticosteroids have revolutionized the treatment of allergic
rhinitis owing to their high safety margin when administered by this route.
Although the nasal mucosa provides an excellent surface
for drug delivery, there is the potential for damage to the
cilia within the nasal cavity, and mucosal irritation is common. In addition, unpredictable mucus secretion among
some individuals may affect drug absorption from this site.
Drops or sprays are often US<'d for their local astringent tffro;
that is, they shrink swollen mucous membranes or loosenS<'cretioIl'i and facilitate drainage. This brings immediate relief
from the nasal congestion caused by the COllUllon cold. The
noseaIso provides the route to reach the nasal sinuses and the
eustachian tube. Proper positioning of the p.1tient prior to
instilling nose drops for sinus disorders depends on which sinusesare being treated. The same holds true for treatment of
OPHTHALMIC ADMINISTRATION
The ophthalmic route is used to treat local conditions of the
~ and surrounding structures. Common indications include e:essive dryness, infections, glaucoma, and dilation of
the pupil during eye examinatioIl'i. Ophthalmic drugs are
available in the form of ~ irrigations, drops, ointments, and
medicated disks. ~ Figure 3.3 (a) and (b) and Table 3.4 (sec-
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OTIC ADMINISTRATION
26
Unft 1
AdmlnlstraUon Guldeilnl!'l
I. Obtain tlitll6tn"lWl patd\, MId rt~ rtIm/I.([,-,tr'sguldtliM1.. AppIicJtion ~It! ,,1(1 hqJtncy of dlinging Iifftr monlilg to m(lflQ\loft.
Z. Apply ~ btfort ha-Jdfil. uu'lOid .b\orpIion of1hu9!!11 by lhf 1IInI'.
l. Rtmovt pmlous melliatioll 01 ~dI.,mdunlt iru.
4. u~ng .1nn!dtrrN1 CJIm.mt, apply lhf ordmd MTwnI. of mftic.Jtion in .n f'lrn IR dirffily on tile jIffIIItiSll"rd P'9" that
'OIIIpilinmeI1lfdiQliGnl .
s.
7.
B. ophlhi1n:
1.a~~dtwithd.ttt,lirH,illdlniti~!..
1. Instruct pHimI to lit l4Ift1ll iii with hud 1i91l~ tiftd bad..
Z. With nondoIIinant hind.lMllowtf lld down ~nt~ 10 expose me COft;,Mjy.1 ~autingJ podeI.
l. o\sk patimt 10 i0oi:. upward.
4. Hold fYt\!1OpIlff 1I4-llSinchaIxNe me COftjl.l:lClr.iI W<.Do!lOl hold dlOflpel ovtI f')t,at th~ 1lIIY M1Wle thf blQtftflex.
5. InRil preaibrd numbft"eI drDpS Inlo the emt!"! oflllt pocRt. A"IOiII tllUdlilg ~III eonjlJlctiYal SlCwith tip ol~.
,. Wapplying lintmmt apPJ. thillile ohimm!"!l1 f'leNy"'9 infl!1 ~ of Iowtr lid rnM9i1. film ~ to l1',li(1' QflthIJl,.
1. Instruct lilt ~ti!11t todolf ~ g!1ltty. ~ gtnIlt prtSSlft with firIge!" to the ~111Kt at Iht irlMf unthlll for 1-2 mlnuttl,.
10 a'IOid owrIIow drainigt iIIo n(llt .and dwoat, thlll nininizilHJ riIk of abIorption into I hf 11IIm1ic dmNtion.
. With t~. f!JlIovt enss fM1Ikation IIOI.Ild eyt.
,.
C.
~k
RtpOOlRpper.DoIKII~~dropper..
1. Instruct patitnl to lit on sick 0110 ~I with he.d ti~rd so tIIIl.fftctrd NO" is l.ti:Ig up.
Z. ntc~ dun 1he pimI of the tar and Iht n\fatus with J <It.n w.a!hdoth 10 p!M!1I "" disdl.Jrgt tom bfing "died Inl0 lhe NI
(,I~I dwilg Ihe
Instl!;jtionllthe ~
l. Hold drawer 114indt KIo"totNr til\il,iII'Id Instill pmuIlfd n!l"nbtfof dropIlnto theWif oflhe t.. Q~ llvwin9l11tdrops to 111M'
downwillll.Moid pI.lciJg drop! dirffiIJ on mr, I)'mpinic IMIIbrilll'.
4. Geotty JpPJ imermittrnt pmSUrt to lhe mgus of the tit Ittltt 01 11M limn.
naSiI~
WPt lIrf Wlkrtiort that rfIIJMt liipped from theNr eN with. tInue.
Z. Draw
1(1'.
mntc1 ~Ok.fIII' of
4. HoIdlhe tip of!he drqlp just i~ IIw IIOIri.ind Mhout ,mini tile IIOIt willi the ~ dirf<1 ,lie soknion literaly tllWild Iht
midilll'lIlIIt supm.:.- mndII ofltt~ rtlm:id bonf.--.rd Iht blStofthe IINI c.Jrity; whm ilwl run down thf throaI.nd ilto tile
Mtachiin wilt.
5. o\sk!he piIimt tornnail in poIition for 5moutt!..
R9~1
AppIy~OjIffi~ay.ndl!iri:alt1htllllJlldtdrnd.
4. ElpOIt 1ht ,a.j~1 oriI'u bJ Itpirnirlg 1ht Iibia ...mh noncSominant hind.
5. Inltft 1ht IlIlIndtd rnddtlw lIIppOSitay ~ 8- 10em along Ihe p!&trior wall lithe Yigila,or.as fiI.as itwil p.m..
'- KUlingi 1MI".,ltj.or 1o.I"g!1l~Y il5fI1 ijlpIic.Jt0l5 CIII.1onij the postfrior~a.j~ Win.nd sicM1ypus/llhe pI\IIqff urtil ffIIplJ.
Rtm~ tIw applicator and pIar;r on i pipft" tClll'd.
1. o\sk the pilimt tol_ ~ and f(l'Nin IJDJ iI the ~ III ~po!iTion lor 5-10 minutn foIowing instnian.
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01",1<,1
TABLE3.4
27
Drug Form
F. rMilsuppWrOOts
Idmlnlstratlon Guidelines
1. InSIrUCI tilt palimt 10 lie on 1m ~de (Sims'po~Iioo).
2. Apply glove;opm 5Uppos~ory and lubriutt I~ bhlll mI.Suppositorifs afl' de~ for tilt rouoded ffid to be f~ng out, toum Itss
pr~SUfl' on t~ inlM\al All ljtlindrr,l~r~ dl'U~~9 tilt palitn~s ~ to push iI OUI.
3.
.. Inform tIM! pa~enl..men lhe stppOIilory iSlo be illll'fll'd;irrstnKt tIM! pa~eIt to take ~ow,deep bmJths ~nd deep~ email! wring
inlffiion, to rriix Ih~ anal5phinctrr.
s. Gtnlly inll'rt tilt IWiYttd mI II supp&Silory into tilt fl'{\lIr\ be)'Ond th~ anal- rMaI ridljl' 10l'rllllfl' rl'r~ntion.
6.
InSlrUClt~
patient 10 fl'main in lilt Sim(p&Sition or lie supilM' to prMnt 9poJsion of~ II.ppOsilory.
7. InSIrUCI tilt patimt 10 fl'tlin tilt supposiroryfor . ,Iull 30 minut~ toalow absorption tOO((\I",1II1ts111it llppJIiIory iladmirillefl'd
to lIimlbtt dtfKilion.
-I'I ,-_~_J
.. Flgure.3J (3) Inl\llilng an ~e ointment
Source: 0 JennyTllomas Phorography.
Ib(
Into the lowerconjun(\lval sac;(b) pressing on the nasolacrimal duct
the eustachian tube. Table 3.4 (section D) and .. Figure 3.5 illustrateimportant facts related to nasal drug administration.
VAGINAL ADMINISTRATION
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The vaginal route is used to deliver medications for treating local infections and to relieve vaginal pain and itching.
Vaginal medications are inserted as suppositories, creams,
jellies, or foams. It is important that the nurse explain the
purpose of treatment and provide for privacy and patient
dignity. Before inserting vaginal drugs, the nurse should instruct the patient to em pty her bladder, to lessen both the
discomfort during treatment and the possibility of irritating or injuring the vaginal lining. The patient should be offered a perineal pad following administration. Table 3.4
(section E) and ,.. Figure 3.6 (a) and (b) provide guidelines
regarding vaginal drug administration.
28
In PtmmKology
drug admlnlstr.Uon
RECTAL ADMINISTRATION
The rectal route may be used for either loul or systemic
drug administration. It is a 5;lfe and effective means of delin'ring drugs to patients who ate comatose or who are experiencing nausea and vomiting. Rectal drugs are normally
in suppository form. although a few laxatives and diagnos.
tic agents are giv~>fI via enema. Although absorption is
slower than byother routes, it issteady and reliable provided
the mediution can be retained by the patient. Venous blood
from the lower rectum is not tronsportcd bywGyofth~ liv",";
thus, the first-pass effect is avoided, as are the digestive enzymes of the upper Cl tract. Table ).4 (Stion F) gives selected details regarding rect;ll drug administration.
'"
,. Flgur~ 1.6 VaglMI drug admlnlsll~tlon:(~} Instilling a V3gtnal supposltory;(b) using an applkiltorto Insnna viglrlal (ream
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OI ...lfrJ PrtndpiesoiONgAdmtnlnratlon
29
10"_15
Epjderm..
....
Subcutaneous
,.,
lei
FlgureJ.7 Intradermal drug administration: (aJ (ross section of skin showing depth of needle Insertion; (b) the administration site
Is prepped;(c) the needle Is Inserted,bevel up at 10_lS0;(d) the needle Is removed and the puncture site Is (overed with an adhesive
bandage
Source: PffIwn fdIKar/oo/PHCoIlege.
~
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INTRAMUSCULAR ADMINISTRATION
An intramuscular (1M) injection delivers medication into specific muscles. Because muscle tissue has a rich blood supply,
medication moves quickly into blood vessels to produce a
more rapid onset of action than with oral, ID, or subcutaneous administration. The anatomical structure of muscle
permits this tissue to receive a larger volume of medication
than the subcutaneous region. An adult with well-developed
muscles can safely tolerate up to 3 mL of medication in a
large muscle, although onlyl mL is recommended. The deltoid and triceps muscles should receive a maximum of 1 mL.
A major consideration for the nurse regarding 1M drug
administration is the selection of an appropriate injection
site. Injection sites must be located away from bone, large
10
UnK I
(Of" (""(epl:<
10 Pho,ma<:ology
A.
Administration Guidelines
inIOOmnaIrOUl~
I. Prtpal! mtdi<lllion in J luberwin or l mL IYrinljt with J prultadItd 16- to 17~UIjt,3/8 to Sl$.indJ 1IffiI1I'.
1. Appy gllI'I~ ard dUII\e injKIion sit~ wilh antiltplic swab il , arrulilr malion. Allow 10 ai dJ.
1. With tho ,n:! indufingtrofllOlllbninanl hand, sprNd lkin taut
4. illffi n~.l'ith bel'ri fuilg upwa!d.al all9l1'of 10- 15".
urtil rntir~ beI'ri isunder mn; donol ,spi"alt.
S.
Advil:U~ n~
6.
7. Withdraw ~ quidl):and pat 5it~ grntlywirh 51ffill' 1 x 1 ~UlI' pad. Do noI mmagl'all'i.
8. il5lnrcl I~ pati~nt noI to lID or !ratd! t~aru
1. Prtp.lll' IlriGliion in J I-to lillL Iyringt ~RIJ J 23- to ZS--gauqc, In-to Sf8.i1Kh nmIlr.For ~rjn.1hr
lI'(ommrndl'd nffilt is 1/8 jndJ and 2S-26~UIjt.
1.
Choo~ W, Jl':idog ill'as of bony prorrioerKl', major ntr'II'~ Jnd ~ood I'I'slfk. For IItparin, dIW: with agmcy
policy fortht ptfrrrtd injKtion !itrs.
4. Appy gllI'I~ ifd ~all\e jnjKIion sir~ with antiltplic swab il , drrulilr malion.
S..... owto JirdJ.
6. BIIlth t~ 5kin ilttWferl th!ll1b~d jndex finger of nondorrifUnt hand or spr~ad tM fftllt,~jl !ltIstJntial
5lbrutantOUl tis~.
7. illffi n~ at 4,'or 90' i oglultprndiog 00 bocIy ~lr:9O' ff obeIr;45" ff i"ltr~ wright Ktht pa~trt ~ '/try thin.
gather 5kin at ilU of nffill' jfllfflion and idminilttr at 90' ~gI~.
8. For nonheparilin"rtion~aspirate 111 Jlliiog bad: on plungtr. Wblood i~n, withd,aw t~ 1IffiIt,liKaro tht
~~d PffPi'~ J new jnjtaion.for htparin, 00 not aspirat~il th~ un dilmaqe SlI"KIIIUlinq tillUtland (jIM
tnri~og.
9.
iljtam~imion!lowly.
10. Remol'l' nttd~ quidd~and grntly malQljt !it~ w~h amis~plkswab. For htpiril,oo noIlIIiISIigt th~ sit~,asltis
may G1U\1' bnisilg or ~ffiliog.
1.
loc.Jl~ site 111 JUdng tilt handwirh I"ftI on I~ grutertnKhanler Jnd thlll1b ItrIIIJrd urrbikus.Poinl totlltanlerior"
iii(!pilll' withtllt indufinger, sprridilg th~ m~ fingerto pointtoward I~ ilii( Ues! {formingJ V).lnjKI
mtrka~onwhn tlltY-!hiptd al!a oftlw induand Itirdfinger.(NoI~:TM ~ how to Iwte I~ventrogk/l~il sit~.)
for IV admiristration.j
(. Apply glon, Jnd 'SItlS injtaion !it~ for ligfll and symptoms ofinllammation or 9tranlOtion.
d.
loc.Jl~ m~j{jtion
~.
(.urfUly in!ffi III'~~ or i(ms dtW~ inlo port and injKl mtdiution.
Wtthdraw 1N'fd~ and mix!Olution by routing (OIluintr!"lld 10 rnd.
----'----"---
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0I ...l<r1
31
2. Toadd aug 10 an IVbolus 11'.1 pYIh) uling aistilg IV iotor IV Iod: Irt'~il):
i . 'krify unltr and tompatibilily ofdlllC) with IV ftuid.
b. DnrrmiottM: torrt'd rat~ ofioflllion.
Co
Dnermint ff IVfl!ithil! infilling it proptr rail' 11'.1 lint) and IhilllI! YI~ ~adtqJal~.
d.
Prepar~ drug
in a ,)Tiogt.
9-
a~n~ tubing or Iod: pori withartilrptit IWaband ilM1 ~dI~ inlo pori.
h. Hadmiri >lffiog mtdititioo IhltlUljh 010 9isIing IV lint, otdlJll!, titling by pinching just i~ lilt iljKlioo port.
SIoII'Iy iojKt mtllic.Jtion!l'm dt5i9:laltll tim~ U\Ui11y 001 fi>ltr tllan 1 mUmin, unlm Iptdfm
j. WiIhdr.w !)'!iogt. R tlu~ tubing.nd mill!! proprr IV infuyoo if lIIDj.o 9istilg IV ~1It.
l
j.
Epidermis
0."..
.-
\'0
~-
Muscle
1'1
Ib)
1<1
Id) """~_
Flgure3.B Subcutaneous drug admlnlmatlon:(al cross section of skin showing depth of needle Insertlon;(blthe administration
site Is prepped;) the needle Is Inserted at a 4S angle; (d) the needle Is removed and the puncture site Is (overed with an adhesive
bandage
Source: Pxson fducor/oo/PH CoI/eg{'.
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32
INTRAVENOUS ADMINISTRATION
(IV) medications and fluids are administered directly into the bloodstream and are immediately avaiL1ble
for use by the body. The IV route is used when a very rapid
onset of action is desired. So with other parenteral routes, IV
medications bypass the enz.ymatic process of the d igestive
system and the first-pass effect of the liver. The three basic
types of IV administration are as follows:
l nt rm~nous
Epidef ",, ~
0"'''''5
.,.
J
jj
Although the IV route offers the fastest onset of drug ac tion, it is also the most d angerous. Once injected, the medication cannot be retrieved. If the drug solution or the
needle is contaminated, pathogens have a direct route to the
hlood.tream and hodytis",,,'_<_P~tient. who ~re reciving IV
injections must be closely monitored for adverse reactions.
Some adverse reactions occur immediately after injection;
yt
''''''''""~
~ssue
Muscle
(b(
(.(
(
,. Figure l.1l Intramuscular drug admlnlstratlon:(a) (fOSS section of skin showing depth of needle Insenlon;(b) the administration
site Is prepped;(c) the needle Is Inserted at a 90" angle;(d) the needle Is removed and the puncture site Is covered with an adheSive
bandage
Source Pruoon fducariofl/PH Ca leqe.
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01 ...1<, j
'\
33
f(}
-,
\~
4
C",,"-
,,
-/
--f
-"
/
Piggyback
Primary
'"'
~,
Piggybar; k"
pri mary
w ith bac kcheck
valva
"'"
C"""'
"\,
...._---'
""""" >",'
(!
(b)
("
FlgureJ.IO Si!'Condary Intravenous lines: (a) a tandem Intravenous allgnment; (b) an Intravenous piggyback (IVPB) alignment
(,' ' - - -
(b)
Figure J.12 IV bolus admlnlstratlon. (a) The part Is cleaned;
(b) the drug Is administered through the port using a needleless
syringe
~
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14
Unft t
The nun;(' mll5t boaVI' a oomprehensive knowledge oflile actions and sJ de efftcts of dru~ before they are admin istered
to limit the number and st'~ityof adver.;edrug events.
l.2
3.1
Topical drugs are applied locally to the skin or membra nous linlngs of the eye, ear , nose, respiratory tract, u rinary
tract, v.lgina. and rectum.
3.1
Parenteral admini$tratio n is the dispensJng of medica tions via a needle, U5ually Into the ski n I~yers ([D ), suoottaneoU5 tissue, muscles (IM), or veins (IV).
3J For pharmacologic campHance, the patient must understand and person~lly aa:ept the value aSSOCiated with the
pteS(;ribed drug regimen. Understandin g the reasons for
noncompliance nn help the nurse Increase th e SUe5S of
pharmacotht'tapy.
lA
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mx
OIIpltll
lS
EXPLORE
fiii!iilllilln3!fir'- -----,
t'I!\e
mo\JfctS,
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Pharmacokinetics
LEARNING OUTCOMES
After reading this chapter,
1.
2.
3.
4.
5.
KEY TERMS
amorption {!alt J!
ilflinity (X1IJt J9
blood-brain barrier paqt 39
conjugates p1IJt40
distribution (X19t 19
drug-protein [om pin (O;1J9
enterohrpatic r!cirrulation paqt4 1
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patIf 0/0
metabolism ~o/O
minimum df~ctiW' (oncentration
pharma(okinflics ~ 11
plasmahalflife (t",) ~42
prodrug meo/O
therapeuticrange fOJI4 2
toxinon(entration patIf 41
~41
("'pI"~
II
physiologic
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37
Plasma membranes consist of a lipid bilayer, with proteins and other molecules interspersed in the membrane.
This lipophilic membrane is relatively impermeable to large
molecules, ions, and polar molecules. These physical characteristics haw direct application to pharmacokinetics. For
example, drug molecules that are small, nonionized, and
lipid soluble will usually pass through plasma membranes
by simple diffusion and more easily reach their target cells.
Small water-soluble agents such as urea, alcohol, and water
can enter through pores in the plasma membrane. Large
molecules, ionized drugs, and water-soluble agents, howe~r, will have more difficulty crossing plasma membranes.
These agents may use other means to gain entry, such as
protein carriers or active transport. Drugs may not nero to
enter the cell to produce their effects. Once bound to receptors, located on the plasma membrane, some drugs activate
a second messenger within the cell, which produces the
physiologic change (chapter 500).
38
UnK I
0"".
J
Distribution
Kidney
j
Urine
capsules. Drugs adminislered in high doses are generally absorbed more quickly and have a more rapid onset of action
Ihan those given in low concenlrations. The speed of digestive motility, exposure to enzymes in the digestive truct, and
blood flow to the site of drug administration also affect ab sorption. Due to the fact that drugs administered IV directly
enter the bloodstream, absorption to the tissues after the infmion i. very rapid . 1M medicatiom take long<'r to absorb.
The degree of ionization of a drug also affects its ab sorption. A drug's ability to become ionized depends on
the surrolUlding pH. Aspirin provides an excellent example of the effects of ionization on absorption, as depicted
in Figure 4.2. In the acid environmem of the stomach,
aspirin is in its non;on;zed form and thus readily absorbed
and distributed by the bloodstream. As aspirin enters the
alkaline environment of the small intestine, however, it becomes ionized. In its ionized form, aspirin is not as likely
to be absorbed and distributed to target cells. Unlike acidic
drugs, medications that are weakly basic are in their nonionized form in an alkaline environment; therefore, basic
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drugs are absorbed and distributed better in alkaline environments such as in the small intestine. The pH of the local environment directly influences drug absorption
through its ability to ionize the drug. In simplest terms, it
may help the nurse to remember that acids are absorbed in
acids, and bases are absorbed in bases.
Drug----drug or food-drug interactions may influence ab.orption. Many ex.omplK of these interaction. have been di._
covered. For example, administering tetracyclines with food
or drugs containing calcium, iron, or magnesiwn can significantlydelayabsorption of the antibiotic. High-fat meals can
slow stomach motility significantly and delay the absorption
of oral medications taken with the meal. Dietary supplements may aIso affect absorption. Common ingredients in
herbal weight-loss prooucts such as aloe leaf, guar gum,
senna, and yellow dock exert a laxatiw effect that may decrease intestinal transit time and reduce drug absorption
(Scott & Elmer, 2002). The nurse must be aware of drug interactions and advise patients to avoid known combinations
offoods and medications that significantlyaffect drug action.
(lIopl" !
ASA- .. HCI
""
(nooionized)
ASA .. HCO.
j
ASA(io";zed)
intestine !pH" 8)
Phann.KOklnetk.
39
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Freo
dfUII
mclecules
(.)
TI_
""~
(')
Figure
::;1'
Capillllriu
, ~ ,
,
TI_
~o
1,,
40
.
,
UtIlI!
COffCooCeptslllPNrmoc"logy
blood-brain barrier to produce actions in the central nerw)us system. In <ontrast, most antitumor mt<!ialtions do
not easily cross this barrier, making brain alnctn difficult to
tre:u.
The fetal-placental barrierservesan important protl'l:tive
firncrinn.""""'''-'I'' il prevenl" pol .. nri~ lI y h"rmful .<uhlr:mC"-'
from ~sing from the mother's bloodstream to the felWi.
Substances s uch as alcohol, cocaine, caffeine, and certain
prescription rued ications, however, easily cross the placen tal
barrier and can potentially harm the fetus. Consequently, no
prescription medication, OTe drug, or herbal therapy
should be taken by a patient who is pregn~nt without first
consulting with a health care provider. The health care
provider should always question female patients in the
childbtaring years regarding their pregnancy status before
prescribing a drug. Chapter 700 pres.ents a list of drug
pregnancy categories for assessing fetal risk.
Firs11"'_
melaooism
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PoI,,1 vein
~
enter hepatic
port~1
(lIopltl4
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Plaml;KOkllM'!Ic:.
41
LIFESPAN CONSIDERATIONS
100119 adull> or middlNge paritnn, btuus~ the older adull poJllllation Ll~
""'Il' drugs .imukllltOUSly (an a"'rage of 1I'1'ffi) than otht r ige grou~ and
b~uUll' of norma Idedi~ in hepatio: and Il'IlII function. (hronic di SNII'S thit
affrct ph"macokinetia 1ft' 1110 p~nt ""'ft' oft~n in older adults. In addition, older adults may not ~illbly Il'pon IMI"II' drug tifls or may [onsmotht m ~ns 01 a9in9 or of their di~ [oooilion. Oflt study (Lamptla t1 oiL,
2007) Ioond lhal when (omp;lring adYl'M rifr[U Il'ported b)' !)Mitnu age 7S
or okll>r with <IMI"II' rifrrts ooted b)' a hukh call' provide~ adVl'I"II' fifro:1"I
well' ft'poned by only 11.4'11. of the patifnts oompared to rifr[U ollll'rYed by
tht health care proYider in 24% of th~ paritnt~ Thf study aUlhor. ft'(ommend
thit h~akh [oJre providm inquift' aboul pD\.Siblt drug-related problems eI'II
though older <Idull"l may not [amp!.in olor II'II-ft'porl IlKh problem~
42
StOJTllld!
Smllil intestine
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of Drug Action
The most common description of a drug's duration of action is its plasma halfli~{tVl)' defined as the length of time required for the plasma concentration of a medication to
decrease by one-half after administration. Some drugs have
a half-life of only a few minutes, whereas others have a halflife of several hours or days. The greatt'T tht' half-life, the
longer it takes a medica tion to be excreted. For example, a
drug with a '11' of 10 hou rs would take longer to be excreted
and thus produce a longer effect in the body than a drug
with a til' of 5 hours.
Tht' plasma half-life of a drug is an essential pharmacokinetic variable with important clinical applications. Drugs
with relativt'ly short half-lives, such as aspirin (t,,, = 15 to
20 ",illUl.,,;) musl [..., ~v"u <:vny 3 lu 4 huurs. DruK' wilh
longer half-lives,such as felodipine (Plt'lldil) (t", = 10 hours),
need be given only once a day. If a patient has extensive renal or hepatic diseaSt', the plasma half-life of a drug will in crease, and the drug ooncentration may reach toxic levels. In
these patit'nts, medications must be given less frequently, or
the dosages must be reduced.
(lIopltl4
"
43
T""
___ .c ~~~_Ii:"!'_
I::,
Thenlp8Ulic
,n,'II"
!,
~
" ,
~
< ,
,
Plaml;KOkllM'!Ic:.
- - Ci.tJ~,;.--
Dum!"", 01 action
.-,
TMIT'Ii
.,
Nltion
,...,
----Th!;.;.-----'."-~-
elled;""
concentmlion
D,
"
Time (hours)
,.. flgure4.6 Single-dose drug administration:
pharma{oklnetlc values for this drug are as fall om: onset of
action = 2 hours;duratlon o f aclion = 6 hours;lermlnatlon of
action = 8 hours afler admlnlstrallon;peak plasma
concentration = 10 mcg/mL;lIme 10 peak drug effect =
5 hours; !'/ , = 4 hours
"
, ~~~~~~~~~~~~
12
24
Time (hours)
Multlple-dose drug admlnlstratlon:drug A and
drug 8 are administered every t2 hours;drug 8 reaches the
therapeutic range faster,becaust' thenrst dost' Is a loading
Figure 4.7
d~
pbsm~
ooncentration in the therapeutic range. Although blood levels of the drug fluctuate with this approach, the equilibrium
state em be reached almost as rnpidly as with a continuous
infusion. Loading doses are particularly important for drugs
with prolonged half-lives and for situations in which it is
critical to raise drug plasma levels quickly, as might be the
case when admin istering an antibiotic fora severe infection.
In Figure 4.7, notice thM it takes almost five doses (48 hours)
before a therapeutic level is reached using a routine dosing
schedule. With a loading dose, a therapeutic level is reached
within 12 hours.
drug
C\ , ' -
4.2
The physiologic properties of plasma membranes determine movement of drugs throughout the body. The four
components of pharmaookinetics are absorption, metabolism, distribution, and excretion.
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44
Un~ t
4.1
45
4.1
4.6
A patient who is in renal failure may haveadiminished ca pacIty to excrete medications. [t Is Imperative tbalthls pa tient be assessed (or ",'hat development?
I . [JH.Te3St'd creatinine lewis
2. [ocreased levelsofblood urea nitrogen
J. Oms toxicity
4. Increased levels of potassium
The nurse understands that with gl~nduJar activIty, '"tersoluble drugs may be secreted into (select all that apply):
I . saliva.
2. sweat.
J. breast milk.
4_ bUe.
5. feces..
4. EIplain why drUg<; metabolized through the first-pass effect might need to be admin istered by the parenteral route.
EXPLORE
[ij;(illlifln3!fiJ'- -----,
fIlursilgKt is
ycu'
one _
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at
Pharmacodynam ics
LEARNING OUTCOMES
After reading this chapter, the student should be able to:
4. Compare and contrast median lethal dose (LD,;o.l and median toxicity
dose (TD,J.
S. Discuss how a drug's therapeutic index is related to its margin of safety.
dinical practice.
Compare and contrast the terms potency and efficacy.
Distinguish between an agonist,a partial agonist,and an antagonist.
Explain the relationship between receptors and drug action.
Explain possible future developments in the field of pharmacogenetics.
KEY TERMS
agonist fll}tSO
antagonist pq50
dficacy piJl}f49
~qurn(Jdiltributim
gradrd dost-responl~
idiosyncratic response
rur'fl' patjl'46
{XIgt 47
Jf!~ 50
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pharmacogen!tics {l!9t 51
pot~ncy ~0/8
~ceptor
pu;e49
46
In PtmmKology
5.1 Pharmacodynamics
'"
and InterpatientVariability
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Choptfl;
,.,
'".
co.
, ""
]
i "'"
z
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, ,
l'h.1rmac:odyn.mk:.
47
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~ '"
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l "'"
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,"
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.~
"",H '
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'00
'"
Oose (log)
Dos ...... response relationship
'"'"
10,000
48
'00
'I
~. "
!
",/
..
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b
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EFFICACY
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to
tOO
1000
10,000
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.. Flgure5.4 Potency and efficacy:(a) drug A has a higher potellcythan drug B;(b) drug A has a higher efficacy than drug 8
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..,
N Ion po!
Binding
8.
segmant.
..
'"".
c
(c) G-ptotein~inked channel
~
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50
'1
i"
i
,
i
o
UnIII
adenosine monophosphate (cyclic AMP), the release of intracellular calcium, or the activation of specific G proteins
and associated enzymes. These biochemical cascades initiate
the drug's action by either stimulating or inhibiting normal
activity of the cell.
Not all rectptors are bound to plasma membranes;
some are intrncellular molecules such as DNA or enzymes in the cytoplasm. By interacting with these types
of receptors, medications are able to inhibit protein synthesis or regulate cellular events such as replication and
metabolism. Examples of agents that bind intracellular
components include steroid medications, vitamins, and
hormones.
Receptors and their associated drug mechanisms are ex tremely important in therapeutics. Receptor subtypes are
h"ing di.cnv,,1"I'<l and n..w medic.",inns a,." h"ing d"wlnped
at a faster rate than at any other time in history. These subtypes permit the fme-tlUling~ of pharmacology. For example, the first medications affecting the autonomic
nervous system affected all autonomic receptors. It was
discovered that two basic receptor types existed in the
body, alpha ani beta, and drugs were then developed that
affected only one type. The result was more specific drug
action, with fewer adverse effects. Still later, several subtypes of alpha and beta receptors, including alpha" alpha"
beta" and beta" were discovered that allowed even more
specificity in pharmacotherapy. In recent years, researchers
have further divided and refined these subtypes. It is likely
that receptor research will continue to result in the development of new medicatioilli that activate very specific receptors and thus direct drug action that avoids
unnecessary adverse effects.
Some drugs act independently of cellular receptors. These
agents are associated with other mechanisms, such as
changing the permeability of cellular membranes, depressing membrane excitability, or altering the activity of cellular
pwnps. Actions such as these arc described as non'pocifi.l1u
lar Il'sponses. Ethyl alcohol, general anesthetics, and osmotic
diuretics are examples of agents that act by nonspecific
mechanisms.
When a drug binds to a receptor, several therapeutic consequences can result. In simplest terms, a specific activity of
the cell is either enhanced or inhibited. Theactual biochemical mechanism underlying the therapeutic effect, however,
maybeextremelycomplex.ln some cases, the mechanism of
action is not known.
\'/hen a drug binds to its receptor, it may produce a response that mimics the effect of the endogenous regulatory
molecule. For example, when the drug bethanechol (Urecholine) is administered, it binds to acetylcholine reptors
in the autonomic nervous system and produces thesameactions as acetylcholine. A drug that produces the same type
of response as the endogenous substance is called an agonist.
Agonisls sometimes produce a greater maximal response
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than the endogenous chemical. The term partial agonist describes a medication that produces a weaker, or less efficacious, response than an agonist.
A second possibility is that a drug will occupy a receptor
andprevetllthe endogenous chemical from acting. This drug
is called an antagonist. Antagonists often compete with agonisls for the receptor binding sites. For example, the drug atropine competes with acetylcholine for spific receptors
associated with the autonomic nervous system. If the dose is
high enough, atropine will inhibit the t'ffeds of acetylcholine, because acetylcholine cannot bind to its receptors.
Not all antagonism is associated with receptors.
FUllctional antagonists inhibit the effects of an agonist not
by competing for a receptor but by changing pharmacokinetic factors. For example, antagonists may slow the absorption of a drug. Ry sp"~ding lip met"~holi.m or eXCTet"ion, ~n
antagonist can enhance the removal of a drug from the
body. The relationships that occur between agonists and antagonists explain manyofthedrug-drug and drug-food interactions that occur in the body.
CNpttr5 I'hormac:odyn.min
51
pharmacogenetic information may someday allow for customized drug therapy. Although therapies based on a patien!"s genetically based response may not be cost effective at
this time, pharmacogenetics may radically change the way
pharmacotherapy will be practiced in the fumre.
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
5.1 Pharmacodynamics is the area of pharmacology concerned with how drugs produce change in patients, and
the differences in patient r"'pon""s to medications.
5.4
Potency. the dose of medication required to produce a particubr response, and efficacy, the magnitude of maximal
response to a drug, orc means of compo ring medications.
5.5
5.6
5.2
5.)
1:1
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52
lInKt
CoreConc<!pl$tnPN,miICOIogy
will cause the release of histamIne when actiY1lted. Compare the effects of an agonist versus an antagonist on this
reu'J'lOr. Whkh WQU]d likely be called an antihistamine,
the agonist or the antagonlstr
!in A.ppmrliJr D for m.slWf'J ,,,,II Mllo.,,'/e! for al/ naMlirs.
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EXPLORE
~---- - - - - ,
*'"
acII_
armacology
nd the
Nurse-Patient
Relationsh ip
CHAPTER 6
CHAPTER 7
CHAPTER 8
CHAPTER 9
CHAPTER 10
CHAPTER 11
SubstanceAbuse
CHAPTER 12
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LEARNING OUTCOMES
Afrer froding this chapter, the 5Ndent should be able 10:
KEY TERMS
.~mm~m
phil! plJlJr55
{I/Jqd9
goal fIIlI1'57
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implementation phaw
jllJlTjIJ
proem {11IJ<'55
outrom.
f'JI1'jIJ
he nursing prOC:fsl is
<I
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56
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TABLE 6.1
Pertinent Questions
(hid" complaint
Ibv do lOO~rI!([\!'saibt)
A~)'OII uptrimciog Ollltr s)TIlproms?l Espffialy pffiiOffit to mtdicitiolllolrt' naw.a, vomiting. ~~, iidJing.
diu inm, !horlMn 01 brt'ath, ntI'/OU!rItSS or inxiouwsl, pllpita~om or ~arl "IIunning. "and Wl'a~s or filtigUl'.)
Do)'OU hal'! a hiltOil of thoot5, hNIl or valCWr (ondiIion~ ~Ialory (ondiIion~ or nl'urologic: (onditions?
Do)'OU hal'! artf dmniIloIogic: (onditions?
folmiylillory
IbvWt'l1't~lIeitedinthep.iIl?Cu~tly?
Whal prtIIJiption mtdicition Sile you amnlly tilting? (Lilt drug naml', dosq, and lil'qumq of idminilt!a~on.)
What non~pIion/lJlC mtIka~omart')'OII tilting? (Lilt IIolme,tIoIaqt. i nd Ir~.)
What ~ pr&riprion or OK. hal'!')'011 takrn willin!hl' plit month or two?
1IoI'I~ 100 Mr UpnitlKN iny sidttllemor !JllllWls)TIlproms with in, mtIka~om? (DeaitJIo)
Is lhere irtf poIIibiily )'011 all' prtgnant? (Alt ewry woman 01 dljlibariog ige.)
A~)'OIIbrt'asHffiiogl
Do)'OU~okt?
WllatisYOOSllOflll.ltikoholintoktl
What is yoos normal uflrinl' intake?
Do)'OU 11M .rtf ll'igious or (u/nnI brlid"s or proKtie (omming mI'lkalkm or yotI' htollth tholt '11'1' !hoWl know about?
Whal is yotI'CKG4JoIlionlWhatlloun do 100 'IIOJII::?
Do)'OU hal'!.rtf (OII(ffl)I rrgaidog in\U!aIK~ or !hi' abi~ly to ifford mNicilions?
~alth
ri51:. hiltOil
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tion. Will the patient require assistance obtaining or purchasing the prescribed medications, or with taking them
safely? \'/hat kind of medication storage facilities exists and
are they adequate to protect the patient. others in the home,
and the efficacy of the medication! Does the patient understand the uses and effects of this medication and how it
should be taken! Do assessment data suggest that the use of
this medication might present a problem, such as difficulty
swallowing large capsules or an inability to administer parenteral medications at home, when necessary?
After analyzing the assessment data, the nursedetermines
patient-specific nursing diagnoses appropriate for the drugs
b~sis
MEDICATION ERRORS
AND DIETARV SUPPLEMENTS
Herbal and vitamin su pplements ca n have powerful effects
on the body that can inl1uen<:e the success of presc ription
drug therapy. In $Ome cases.o\"tr-the-coun ter supplements
cr.n enhance the effects of prescription drugs, whereas in
other insran<:es supplements may cancel the th~rapeutic effectsofa medication. Fore.umple.many patients with heart
d isease take garlic supplements in addit ion to warfarin
(Cownadin ) to pre\"tnt clots from forming. Because garlic
and warfarin are both antiroagulants. taking them together
could result in abno rmal blK'ding. AI. another example.
high doses of calcium supplements can cancel the beneficial
antihyperteru;ive effects of drugs such as nifedipine (Procardial, a cr.lciwn channel blocker.
Few controUed studies have ex:lmined how concu rrent
use of natural supp lements affects the therapeullc effects of
prescription drugs. Patients should be encouraged to report
use of all over-the-counter dietary supplements to the
health care provider.
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and Outcomes
The planning phUI' of the nursing process prioritizes diagnoses, formulates desired outcomes, and selects nursing
interventions that can assist the patient to return to establish an optimum level of weUness. Short- or long-term goali
are est ablishe.:l that fOCll'S on what the patient will be able
to do or achieve, not wha t the nurse wi)) do. The objective
58
Rill::forlnjul}
Offidtnt I(nowld9!'
Anl:i~
HiUIN
Dffiustd CardioKDuIpU
Honromplii()(~
ImbiliuKtd Huu~ion
Erha'xtd (omfort
umtipation
Risk for {onlaminalion
""
Intff~CopiIl9
StIHn DtfKil
RiIUorPoilOlling
[hrrllei
MorilDillr~
Stxuai OyIfunction
RiskforFilk
Fitigue
Strns<lvfllNd
En~1 FluidVolume
Rill::forSlidde
Impai~ Gas
ImpaR d SwilioowilHJ
Enhill4}e
Uriniry Relention
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Non- English-Speaking
and Culturally Div@ulitPatilitnu
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of Medications
The tvaluiltion phair compares the patient's current health status with the desired outcome. This step is important to determine if the plan of care is appropriate, if it was met, or if
it needs revision. If it was met, the plan of care was appropriate, and the problem or risk was resolved. The nurse and
patients can then address the next highest priority health
60
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Medication ministration
(an)'Oll t~1I1IM' hOI\' mum oftht IIM'IiGflion)'OU should ta~? (milligram~ numbl'r oftab~t~mililitmoflirpd, ~\(.)
(an)'Oll t~1I1IM' how oft~)'OU shoWd taU~?
Whal ~llI'qLifl'lllenuall' ntmSlIl wIIffi)'Oll take this lIM'Iiution? (~.g.!au- w~h a fUlglassofwalef, uu- on an
empty SIOmad1, and remain upri9:lt for 30 minUll'sj
k thffl' i loptdrK OIdtrin whim you sIlood taU- 1011" medications? (~.g.,using i brondIodilator brfor~ using a
cortkost~roid imller)
(an)'Oll shOll' ml' how you willljft YIMI"ltIf!he mtdKation? (r .g., r)'l' rtops, SltxUlanaus injraions)
What spffial monitoring is r~rtd btfOll')'OII takethis OII!diution? (~.g.ptR rat~) Can you dtmonSUil~ this fOlIlM'?
Bastd on tllal mon~orinq. wIIffi should )'OIl nor tak~ th~ 1IM'Ii<a~on?
Do you know how,orwllefr. to ROR' this mtdkadonl
AII'!he1l' i OY sptdal ttlts )'OU should ~ rriaRd to this lIM'Iiution? (~.g. fi~-Slid. gllKose ltoIrk.lhffilpeutic drug
'''''
Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapler. If any of these points are not clear, refer to the nWllbered section within the chapter for review.
6.1 Assessment is the systematic oollectionofpatient dahl.Assessment of the patient receiving medications includes
health history information, physical assessment data, lab
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6.2
Nursing diagnoses are writtl'n to address thl' patil'nt's responses related to drug administration. They are developed after an analysis of the assessment data, are focused
on the patient's probll'ms, and are wrified with the patient
or caregiver.
6.3
II
1:1
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EXPLOflE
~ .- - - - - - - ,
Drug Administration
Throughout the life Span
LEARNING OUTCOMES
After re/ldlng Ih/s chapler, Ille sludenl should blr able to:
1 . Describe physiological changes during pregnancy thai may affect the
absorption, distribution, metabolism, and excretion of drugs.
2 . Describe thl! placentaltran5fl!f of drugs from motherlo infant.
3. Match the five FDA pregnancy risk categories with their definitions.
4 . Identify fa ctors that influence the transfer of drugs Into breast milk.
5. Identifyte<:hniquM Ihat the breastfeeding mother can use to reduce
drug exposure to the newborn.
9.
KEY TERMS
older adulthood fX19' li
f'OIT 71
embryoniqM!riod f'Il1"65
polyphmnacy fXJI" 7l
ft1il~riod fllJlY65
p~implantat~n
adolf'l{~n(f
infilnCY fllJlJ'68
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period fXJI"65
prfl(oool child fXJIJ' 70
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7.2 Pharmacotherapy
of the Pregna nt Patient
Drug therapy in a pregnant ]Xltient requires that the nurse
coruider the effects of the drug 011 both the mother ao; weU as
on the growing fetus. The plx,nta isa semipermeable membrane: Some substances readily pass from m()ther to fetus,
whereas the transport of other substances is blocked. The feW merrbl"lllles rontain enzymes tlut detoxify certain substances ao; they eross the membrane. For example, insulin
from the mother is inactivated by placental enzymes during
the early stages of pregnancy, preventing it from reaching the
fetus. In general, drugs th.:lt are wate!" soluble, ionized, or
bound to plasma proteins are less likely to cross the placenta.
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55
FmI period: The fetal phase is from 9 to 40 weeks postconception or until birth. During this tim e, there is continued
growth and matunltion of the baby's organ sys tems. Blood
flow to the placenta increases and placental vascular mem branes bewme thinner. Such alterations maximize the transfer of substances from the maternal cirrulation 10 the fetal
blood. As a result, the fetus may recei\'c brgerdoses of medicatioru; and other substances taken by the mother. Because
the felus lacks mature metabolic mzymes and efficien t excretion medtanisms, medialtiom will have a prolonged dura_
tion of adion within the unborn child. Exposure to
lenltogms during the fetal period is more likel y to produce
slowed growth or impaired orga n function, r.ilher than gross
structural malfonnatiom.
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66
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Interpretation
~t~ Wfi,ontrolN
""",
Pmdllils,rtphalosporin~azithromydn.oJ(~t.lminop/lffi.
OR
Anilllil15lod~s h.w~ !hown.n adYers!' rfl'ta. but adtqwt~aOO
MI~rontrolltd
MI~rontroll~d
OR
w~~rontrolled stLde
because very high doses in laboratory animals often produce teratogenic effects. All category D and X drugs should
be avoided during pregnancy due to their potential for causing serious birth defects. Because a woman may obtain a
prescription before she knows she is pregnant, it is crucial
that the nurse ask all women of child-bearing age if there is
the possibility of pregnancy as part of the routine teaching
that accompanies giving a patient their prescription.
PREGNANCY REGISTRIES
Pregnancy registries help identify medications that are safe
to be taken during pregnancy. These registries gather information from women who took medications during pregnancy.lnformation on babies born to women not taking the
medication is then compared with data on babies born
while medication was taken during pregnancy. The effects
of the medication taken during pregnancy are then evaluated. Registries may be maintained by drug companies,governmental agencies, or special-interest groups. Examples of
pregnancy registries include the following:
Antipsychotic medicines: http://www.motherisk.orgl
womenlindex.jsp
Antiretroviral medicines: http://www.apregistry.coml
who.htm
Asthma medications: http://otispregnancy.orgl
Epilepsy medications: http://www2.massgeneral.orglaedl
Autoimmune disease medications: http://www
.otispregnancy.orgllunlinside. php?sid= 7&id=40
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7.3 Pharmacotherapy
CNp1fll
ABLE 7.2
67
ibutolol~
If19OItmion:tw~rdii;~
iIIiodMant((onInnt)
~sm
~MI'Ii'Ie
~.poorsltepilgpHtem
~~
atenokJl {lmlmIinj
(j1l'lOlls: ~
Imr10aiptinf (hrIodtI)
(BI~
.....
CoaInt il'll0IDuc1on:klbl;litJ. ~
~ntntlttl'l~\ti!lJrtI
rf9OIl11inr (EJgDltat)
~dilf'rI~i.(OIMA!ions(dost'I UIfd in
migrW.e ~tMioru)
nuoe~~
(Prout")
haloptridol (HaIdd)
lithiLm (Elbith)
p/lffiindioM
phfnobarbilal(wminil)
jrim~
melhtmoglobilemia
~Ion, ~ probItms
pirtialth~stinti~
m~k contili'lng Fi'enoNlbitil.
(Mpdine)
IlMNiziIe (AnMdne)
1I'*" .... nm
Selected drugs that enter the breast milk and have been
shown to produce adverse effects are listed in Table 7.2.
It is important to understand facton that innuence the
amollnl nf tlnl!! MCretM ;nln h.",a~ ' milk. Thi~ allnw~ the
nurse to aid the patient in making respon5ible choices regarding lactation and in reducing exposure of her newborn
to potentially harmful substances (.- Figure 7.2). The same
guidelines for drug use apply during th e breast_feeding period as during pregnancy-drugs sho uld be taken only if
the benefits to the mother dearly outweigh the potential
risks to the infant. The nurse should explore the possibility
of postponing pharmacotherapy until the baby is weaned,
or perhaps selecting a safer, nonpharmacologk therapy. If a
drug is indicated, it is so metim es useful to administer it immediately after breast-feeding, or whe n the infant will be
sleeping for an x tended period, so thai time elapses before
the next feeding. This will usually reduce the concentration
of active drug in the mother's milk when she later breastfeeds her infant. The nurse c;rn assist the mother in protecting the child's S<lfety by teaching her to avoid iUidl drugs,
a1oohol , and tobacco products during lacta tion.
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When considering the effects of drugs on the breastfeeding infant, the 1UIWlint of drug that actually reaches the
infant's tissues must be considered. Some mediauions produce no adverse effects beawe they are dest royed in the in fant's G I s~tem, or are unable to be absorbed across theG I
tract. ThlH, although many drugs a~ .!rctro in bt-U.51
milk, some are present in such small amounts that they
cause no noticeable harm .
The last key fa ctor in th e effect of drugs during bClation
relates to the infant's ability to metabolize sm all amo unts of
drugs. Premature, neonatal, and seriously ill infants ma y br
at greater risk for adverse effects bec;ruse th ey la ck drug metabolizing enzymes.
So me recommendations regarding mediutions given
during lactation are as follows ( Halt, 2004):
Drugs with a shorter half-life are preferable. Peak levels
are rapidly reached and the drug is qukkly cleared from
the maternal plasma, which reduces the a mo unt of drug
exposure to the infant. The mother sho uld not breastfeed while the drug is at its peak level.
Drugs that ha'e long half- lives (o r active metabolites)
should be a'oided beause the y c;r n accumulate in the
6B
Unftl
ReI~!Ion"'lp
All
ore
drug>.
Understand that the adverse effects o( drug treatment
may be confused with common discomfortli of
pregnango beca use they may be similar. These wmmon
discomforts include nausea, vomiting, heartburn,
coll'ltipation, hypotension , heart palpitat ions,and
fatigue.
DRUG ADMINISTRATION
DURING CHILDHOOD
As a child develops, physiC4l1 growth and physiological
changes mandate adjustments in the administration of
medications. Although children may sometime-s receive
similar drugs via the same routes as adults, the nursing
management for children is very different from that for
adults. Normal physiologic changes during growlh and de_
velopment can markedly affect pharmacokinetics and
pharmacodynamics. Factors for the nurse to consider in~
dude physiological variations, maturity o( body systems,
and greater fluid distribution in children. Drug dosages are
vastly different in children.
For the purpose!; of medication administration, the pedi_
atric patient is defined as being any age from birth to 16
years and weighing less than 50 kg. Additionally, children
may be classified as neonates, in fan ts, toddlers, prt'$Chool ,
sdiool age, and adolescent.
Fig~
urI,' 7.2 ). The first 28 days of life are referred to as the
PHARMhCTS
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neonatal period During this time, nursing care and phannatow:lrd s:lfelyof the infant , proper 00._
ing of prescribed drugs, and teaching p<lrents how to
administer medications properly. A primary goal is to have
the child ingest the entire dose of medication without spitting
it oul because it is difficult to estimate thumount lost. If the
child vomits immedi~tely after taking the drug, the dose
may be reordered. The following nursi ng interventions and
parental teaching points are important for this age group:
cotru>rapy~ ... direct...!
diarrhea.
Medications are often administered to infants via
droppers into the eyes, ears, nose, or mouth. Oral
medications mould be directed to the inner cheek and the
child given time to swaUow the drug to avoid asp iration.
If rectal suppositories are administered, the buttocks
69
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70
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7.7 Pharmacotherapy
of Preschoolers
and SchoolMAge Children
The p~Khool ch il d ranges in age from 3 to 5 years. During
this period, the child begins to refine g ross and fine motor
Lt FESPAN C ONStDERAT tO NS
Iron Poisoning
One of tht It.lding WIllS of poilonings in thildrm undu t~ "9t of 6 is iron
poisoning.lron il oltm found in vitaminl of .11 kincb: plfllal.l~ ptdialrit..lnd
aduk vitaminl.Ptdiatric vitaminl may bI' ~rtiwlarly tmpting and may hal'!'
tht mtt and .lpptmn, of a ndy that tht ,hild il familiar with. Plt'lWtal vitamins molY hold .l ~rtic:ulardangerduetot~ ilK~a!td amounts ofiron and
011itr romponenll. And vit.minl all' not ,lw.l~ ronlideft'd"mtdicilll' or Iod:ed
INlay with other pmription mtdiationl. 0Idtr ,hild Il'n may optII tilt bottlt, 0
yoong{hild mayoutwita"{hild-rt5ist,m"top,or .. bot1lt is ItIt within tilt mild's
rNth.llfpendilg on tht oJ9I.' oltht mild,aI IN aI 1M irolKont,ining I.IbIt~
all' known to t,lISI' iron poiloning.
SymplOml ofiroo poiIonil"f;l intkJlt nau!I'.l, l'OIIIitinq. diarrhN,gastrointe tinal
blHfii"'J, ond u n fK"'JJP In rMkI.nd ....nh.Fw-n if inn poi<nninoJ i< Dn~ <II<peatd,tht mid IhoUd bel.lktn br mtdic.il f"l<\Wtion brallSl' symplOml may
bl'drb)'edPaft'llU!hoo1d be tIKOUfoJ9I.'d to be ,n,in ~ rnediution, ird:rding
OK dnJ11 5U1h as vitamins,.l1l' Iod:ed away and rntdi:irr bonlt topUIl' StnUM
And....t.tn viliting aoother horne or hawil"f;l .l visitorwithin tlr ~ bI' lUll' ,II
meditation is out of .J mid's INth and mbbility, Mfl vitamrn.
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71
5o/JrCI': PeaWfl
fliJcQr/ooJPHCoilege.
PHARMFACTS
Po isoning
"'cording 10 tht National Erntf9t1K)' Ikdiul MlOXialion (NEIM):
Yc:h ~~~ 2 million Ameriunull' poison~d
Poisoning "n bf plt'Vrnltd tfJrough ~dK,lIion ~ nd aWilll'ntU.
Min~ poisonings 0((111 in (hildren under6 )'ears of illt.
hlukl (in bf poisontd b)' taking t~ wrong dose of mtdiution, ronliJling
d~ll'nt mtdkations,or i(cidtntill~ splashing a poison on 11M- skin or in
Ih~t)'l'S.
7.8 Pharmacotherapy
of Adolescents
Adoll'S(~ncf
occurs between ages 13 and 16 years. Rapid physical growth and psychologic maturation have a great impact
on personality development. The adolescent strongly relates
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DRUG ADMINISTRATION
DURING ADULTHOOD
When considering adult health, it is customary to divide this
period of life into three ouses: I"'ung .dulthood (IS to 40 year>
of age), middle.d ulthood (40 to 65 years of age), and older adulthood (over 65 years of age). Within each of these divisionsare
similar biophysical, psychosocial, and spiritual characteristics that affect nursing and pharmacotherapy.
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Figure 7.S
7.10 Pharmacotherapy
of Older Adults
DurinI'! ll,,, 20lh L,,"tury, anllllpruvoo <ju~lity ufli[" ~",J lh"
ability to effectively treat many chronic diseases contributed
to increased longevity. The age-related changes in older
adults, however, can influence the patiE"llt's response to
drugs, altering both the therapeutic and adverse effects, and
creating special needs and risks. As a consequence of aging,
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73
74
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....
ku:llyor!houtinq.epeWllyifhNring~i~areusrd.lfilitlMalOOUmofbadt
Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the nWllbered section within the chapter for review.
7.1 To contribute to safe and effective pharmacotherapy, it is
essential for the nurse to understand and apply funda mental concepts of growth and development.
7.9 Young adults constitute the healthiest age group and gen erally need few prescription medications. Middle-aged
adults begin to suffer from stress-related illness such as
hypertension.
7l
73
7.5
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7.8 P}wrntacologic compliance in the adolescent is depen dent on an understanding of and respect for the uniqueness of the person in this stage of growth and
dewlopment.
(MhA) was founded. From 1852 to 1975, two major compendia maintained drug standards in the Un ited Stat es, the
U.s. Phurmacopoeiu and the Nutionul Formulary (NF) established by the APhA. All drug products wne covered in
the USP; pharmaceutical in gredients were covered in the
NF. In 1975. the two entities merged into a singl e publi catiOll , th e U.S. Pharmilco/'Mill- Niltionill Formlda,y ( USPNF) . Th e current document of about 2,400 pages contains
3,777 drug monog raphs in ]64 chapters. Official monographs and interim revision announcements for the USPNF are published regularly, with the full bound venion
printed every 5 years. Today, the USP label can be found on
many medications verifying the purity and e.xact amo unts
of ingredients found within the container. Sample labels a re
illU5trated in ~ Figure 1.\.
In the early 1900s, the United States began todevdop and
enforce tougher d r ug legislation to protect the publ ic. In
19UZ, the BiolOSlcS Control Act helped to standardI ze the
quality of serums and other blood- related products. The
Pure Food and DrugAct of]906 gave the government power
to control the labeling of medicines. In 1912, the Sherley
Amendment prohibited the sale of drugs labeled with false
therapeutic claims that were intended to defr:lUd the con sumer. In 1938, Co ngress passed the Food, Drug, and Cosmetic Act. This was the first law preventing the sale of drugs
that had not been thoroughly tested before marketing. Later
amendmen ts to th is law required drug companies to prove
the safet y and effiOKY of any drug before it could be sold
within the United SUtes. In reacliOll to the rising popularity
of dietary supplements, Congress passed the Dietary Supplement Health and Education Act of 1994 in an attempt to
COlIIroI misleading indu.m y daims. A brief timdine of ma jor events in U.S. drug regulation is shown in ~ Figure 1.2.
_0___
....r..oc"""',_
-,
Idb
Ih1fu
' II
Un
R
lblln-Sli'
~tI
_
_ ~ _ 2D.
_
'00_
-_--.---,
--....
.. ~-
_
.. _
--,
-_
........ Restoril"
...... _
.---....."".i!.
---,
b_
----"'n.....,.
_ _
--~
-~
....
- - -~
. -.110. ...
- ,-
II
Ii
o.ce ~,,.."
l00~".
temazepam
. es.USP
_--
_tM' _.'.~_
Ar.tIinotIr1odf
"".
-i!i- ,~ I,
-,
~~
MaIItrcbodf PtIoImocrotlcois.
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"
PHARMFACTS
......
thtmid-199Oi.
Psychosocial, Gender,
and Cultural Influences
on Pharmacotherapy
LEARNING OUTCOMES
After reading r~J chopfer, rhe student $hoold be DOlt to:
pharma(otherapeutk outcomes.
-,....
KEY TERMS
rull1nl compnolKf
pi1Jt J8
mMcitypqlB
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geHticpolymorp/IMI pi1Jt~
holillK ,.,17
hlllllM illegratiol 'JfK1id poqrll
phamiCttHetia JIIlIJ'1JO
psydlosMiil tnT II
spirilu ily fIIJ9t II
C1up1frl
was explained in terms of differences in drug-receptor interaction s. Chapter 7010 examined how pharmacokinetic
77
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8 .2 Psychosocial Influences
on Pharmacotherapy
The term psy<hosocial is often used in health care to describe
one's psychological development in the oontext of one's social
environment. This involves both the social and psychological
aspects of a person's life. Spirituality incorporates the capacity
to love, to con~ compassion and empathy, to give and forgive, to enjoy life, and to find peace of mind and fulfillment
in li~ing. The spiritual life overlaps with component! of the
emotional, mental, physiClI, and social aspects of living.
From a health care perspective, every human being
should be considered as an integrated psychosocial, spiritual
being. Health impairments related to an individual's psychosocial situation often require a blending of individualized nursing care and therapeutic drugs, in conjunction
with psychotherapeutic cOWlseling. The term psycho-socialspirimal is appearing more frequently in nursing literature.
It is now acknowledged that when patients have strongspiritual or religious beliefs, these may greatly influence their
perceptions of illness and even affect the outcomes of pharmacotherapy. When illness imposes threats to health, the
patient commonly presents with psychological, social, and
Age COIO'aries
Geode. Detarrnnants
Psychoiogiclll-5ocial-Spiritual Dimanaion
78
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on Pharmacotherapy
Although often used interchangeably, thedefinitions of culture and ethnicity are somewhat different. An ethnic group
is a community of people that share a common ancestry and
similar genetic heritage. Ethnicity implies that people have biuluKi~ ~",.l K,,"di~ siII1il~rili"". (ul tu,~ is ~ sd uf belief" v~l
ues, and norms that provide meaning for an individual or
group. People within a culture have common rituals, religious beliefs, language, and certain expectations of behavior. Cultural and ethnic variables are important aspects of
patient care that directly relate to pharm.1cotherapy. Both
have a profound influence on patient outcomes and the oc-
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Medication Adherli!nce
Poor adhertOO' to.J pre5aibtd mtdirnion is brcomi~ known >IS Ammca's"other
drug probltm" but roe that has hNlth ind fillinciil ~ MIl 'lNler
thin sU!st.J~ ilKu.lt is estin.Jttd that appro:lirwel)o ~ oftht 2 bilion PII'scriptions filfd ~ach )'N' all' taktn inrorrectIy; while Oil!' third of P.Jtiftm talr i l
of thei" mtOOtion.roe llird talr sornt, ind OIl!' thid do IDtIiR.JOY .J1 i l or
Dn'eIfilltht~tilllApproxinatdy 13%ofrmilgllomeadmMionlmaybe
cU to poor rneO!ation adhertoo' and is many is 10% of al hospiLJl admissions.
Iht mtOOly urdersernd popuIition,A'lltn[,lRsof all erhric badqoonds who
all' pool; Lrl; hNlth inlUl<ll"a, or h.M Ndrqu.J1~ oJ((fIS to heikh GIli', all' Oil!' 01
!ht 91tl.p1111011 il risk.
Ibz Il'I'/e a vitil
in ilKft'iSi~ mtdK.imn mll'ra, both btcaust 01
!ht trustIU II'Lnionship nurse rstablish with their P.J00rts, and betause they all'
oftrn the main IOU~ 01 medication tdJGItion for tht P.Jtimt and thei, fami~
PMYiditg simpif drug inbnnation to help thr P.Jtitnt urderst.wl why J mtdiation is 1I'qUiRd, I'IIIffi and row it shedd be taktn, and when to ull!ht hNkh Ull'
proMie, is vitalilbrmation to help illONll' mtdiGItion mltoo'. With ~OKh SIK(filM hNlth UII' Yisit. the nu~ Gin go OY!'I the rneO!ation h~tory,askiJg tptItions ibM pmcribtd mtdirnions, being alert to reports thai the P.Jtimt iI not
takitq. or is net tal:i1g rorrectIy, tilt preaibrd drugs. As KOOOIIlK (onditiJns
sometimrs II'IUk iI tifIiam t1Ki!ions belWfen obuiri~ mtdK.J1ions and other
lI'qUill'd flt(ffiitifl,lIJ~all'a~ the hNlthull' proYidmil tlltbrrirontol
proYiIitg mtdiGItion mation ind foIllw-t4J that willlI'IUk iI poMtr..r rutrollrl to htalth and prMnlilg nrgatiYe hNlth ~fIeCtS. andMlllarger~i
tull'l,asa II'IUkoi poor III!'ditation adhererl(f.
"*
79
PHARMFACTS
fur
(huu,~",.b
uf r~~"
~"ct
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FI9ur,8.1 Anurse communicates with her non-Engllsh-spea klng patient through an Inlerpreler
SOUrce; A1000n EoPJCorloolPH College.
;;
,i
f
i
,
o
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PHARMFACTS
......
"".
o thers wi thin the s~me group for hundreds of genera tions .
Although geneti c poIymorphisms are generally rare in the
over:r.U population, specifK ethnic groups can sometimes
express a very high irKidence of these defects.
Choplfrl
Culrur.llnlluenc:", on PNrm.mthe<apy
81
Result of Polymorphism
A(tlyltralilferall'
Dtbrisoquin IrJdrox~
The relationship between genetic make-up and drug response has been documented for decades. The firsl polymorphism was discovered in acetyltransferase, an enzyme
that metabolizes isoniazid (INH), a drug prescribed for tuberculosis. The metabolic process, known as acetylation, occurs abnormally slowly in certain Caucasians. The reduced
hepatic metabolism and subsequent clearance by the kidney can cause the drug to build to toxic levels in these patients, who are known as slow acetylators. The opposite
effect, fast acetylation, is found in many patients of Japanese descenl.
In recent years, several other enzynte polymorphisms
have been identified. Asian Americans are less able to metabolize codeine to morphine due to a genetic absence of
the enzyme debrisoquin, a defect thai interferes with the
analgesic properties of codeine. Some persons of African
American descent have decreased effects from betaadrenergic antagonist drugs such as propranolol (Inderal),
because of genetic variances in plasma renin levels. Another
set of oxidation enzyme polymorphisms have been found
that alter the respollse to warfarin (Coumadin) and diazepam (Valium). Table 8.1 swnmarizes the three most
common polyrnorphisrns. Expanding knowledge about the
physiological impact of heredity on pharmacotherapy may
someday allow for personalization of the treatment
process.
is:;ut:,~
aluug
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82
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KEY CONCEPTS
The nu mbered key concepts provide a succinct summary of the important points from the corresponding numbered section
wIthIn the ch~pter. If any of these points are not dear, refer to the numbered section withln the chapter for review.
SA
S.5
S,';
83
NCLEX-RNOREVIEW QUESTIONS
D
The patient informs the nurse that hewill use herbal com
pounds given by a family member to treat his hyperten sIon, The approprIate action by the nurse Is to:
1. Inform the patient tIlat the herbal treatments will be
inetrediVl'.
2. obtain more information and determine whether the
herbs are comp~tible with medicatIons prescrIbed
3. notll)' the physlclan ImmedL1tely,
4. inform the patient that tile physician will not treat him
if he does not accept the use of traditional medicine
only.
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EXPLORE
~rsiIlQIOt
1m, aninatilm
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Medication Errors
and Risk Reduction
LEARNING OUTCOMES
After reading this chapter, t~ student should be oble to:
1 . Define medication error.
3.
7.
KEY TERMS
rrwdication administration I'KlJ'd (MAR) fIIlI1'8iJ
m,dicatim 'ITOr fIIlI1'lJj
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polypharmacy pogtl/(J
rill! management fIIlI1'91
Chop''' 9
cau~c
~a ny
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85
86
UnK2
---.--C~lIInoe s
or .......malhat
ha.... capacity
10 causa erfOf
H.~
t, .... tmont
Intervention Necessary to Sustain Lil.
1rn;ludeIi cardiOVllscUBr IIIld respiratory liUWOrt
(e,g" CPR, do~brillatiOf1, int<b&tion, ele,)
----.----
Category F
Iho_--. .. ,) r
____O'=O_ _ _ _--<
Figure 9.1 Index for Categortzlng Medication Errors Algorlthm;see al'iO Figu re 9,2,page 89
Sour,,,, 0 1001 Naflonal Coorrifiaflng Camell for Medlcaflon Error Reporrfig and Prwl'flr/oo, All rlghtl reserved,
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87
Intended Meaning
Common Error
"
Un~s
Miltam. i l i moor i fOIl' (4) lI'5Uhing in lW~rdOII'.AIIo mistakm for'"' (cubM: (rJliml'l~nl whm poorly
'NIiIttfl.
.,
....
Mimqallll
The pffiod afl:~t~Viul _imtlbffiJ mimktn for ~ "I, ' ind iIH' aug has bffiJ gi'ml "OID'(kIII"
~~ daly) rathtrthan daily.
Milinterpreted as "Oil" (daily) or"OID' (fOIl" tiMl dal ~ ).If t~ "0' is pooIt1 'NIiItl'fl, it loot! ~ke i pfflod or "I:
so
SubruuntOOl
tiw
~timeaWffl;
"
htimft meditationliul'!' bffiJ prtINnm, dittontimll'd wIIffi O/C, (intfflied to mI'~ "discharge") Won
misill~edil"dKoo~nue, ' btuu~ ~was foIowrd by i list of drug!.
W.Hnrtngth
UD::(mtiml'l<'n
AU,AS,AO
Mitinl<'rpretod as th~ L1~n abblniation ' 01./"' (both ey~ );"OS" (idt ey~);"OD" (rillt ~,r).
Itft~a~rj,jllur
'"
Inwnational unit
Nort: From the Nationil Cocninating (0000 for MedK.ittion Error Rrponing and P~1ion, Cl I998- 100/i.AlI Rights Rl'sm'ed.
HOME
&
COMMUNITY CONSIDERATIONS
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counttr (OTC) drugs, biologics, medical and radiationemitting devices, and special nutritional products. The FDA
encourages nurses and other htalth care providers to report
medication errors for its database, which is used to assist
other professionals in avoiding similar mistakes. Medication
errors, or situations that can lead to errors, may be reported
anonymously directly to the FDA by telephone or online.
Since 1992, the FDA has received over 30,000 reports of
medication errors. The number of actual error6 may be
much higher.
A second organization that has been established to provide assistance with medication errors is the National Coordinating Council for Medication Error Reporting and
Prevention (Nee MERP). This organization was formed
during the Pharmacopoeia Convention in 1995 to help
standardize the medication error reporting system, examine
interdisciplinary causes of medication errors, and promote
medication safety. Nee MERP coordinates information on
medication errors and provides medication error prevention education.
88
Unft2
theNurw-P~tlE<lt
R.... tlon$hlp
complica tions. Failure to report nursing actions implies ei ther negligence ( i.e., no int erventions were taken) o r lackof
acknowledgement that the incident ocwrred. The nurse
should also document all individuals who were notified of
the error. The mdiution adminillration IfCord {MAR) is another
source that should contai n information about what med ication was gi"en or omitted.
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Chop''' 9
C.-gory t.
M error oocurred thE
may h_ contributed to
or ruoJted in the
paenfa d.... th
c.r;....., A:
~"OI
DefInitIons
Harm
Impairment 01 the
physical, emotional, or
p,!I)o'd>oIogicallunction 01
Cat~ H:
~ 8:
.....,
Cetegory G:
An ........ occu .... d thal
""'Y hit.... contribut.. d to or
... sulted in permanent
patient harm
C ..egoryC:
An . rror <>CaIfT1Id that
the p.-ient but did nee
".... pAtient harm
...
hospitalization
" - ''''
the palilKllltnd
raquired inter .... ntion
Error, Death
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Int.rvention
May include change
in therapy 01 ltCtive
medicallsu'llical
N.c.... ryto
Su.tain Life
Includes cardiova!IaJlar
and resp;ratory 5,-"""rt
(e .g., CPA, doIibrilation,
intubation)
...... tedin
Error, Harm
Mon~oring
Int.rv.ntion
tomporvy harm to
thero/rom
tmalment
Error. No Harm
Cetegory F:
An e ""r occu .... d that ""'Y
ha.... contributed to or
I"85OJtod in t.. mporary
harm to the pat .. nt and
reqli ... d in~ial or
89
occurred in patients older than 60 years . There is an increase in the risk for er rors in the elderly population because they often take nwnerous medications, have
multiple health care providers, and are experiencing normal age-related changes in physiology. Children are another vulnerable population because they receive
medication dosages based on weight (which increases the
possibility of dosage m iscalculations), and the thempeutic dosages are much smaller.
Nurses must be vigilant in keeping up to date on pharmacotherapeutics and should never administer a medication
until they are familiar with its uses and side effects. There
are many venues by which the nurse can obtain updated
medication knowledge. Each nursing unit should have current drug references available. Nurses can also call the pharmacy to obtain information about the drug or, if available,
look it up on the Internet using reliable sources. Many
nurses are now relying on personal digital assistants ( PDAs)
to provide current information. These devices can be updated daily or weekly by downloading information so that
the information is current. Nurses need to familiarize themselves with research on preventing medical errors to maintain evidence-based practice skills.
I 0 No Error
L ifESPAN CONSIDERATIONS
arpn
Sf_ mimg mediutirn intoa bJI.~or CDIIdintnl, btUll!
rna,
to OIh~, (.~i.e".
effect comidmd.
The Elde rl y Population
~berttru the frtqutlK)'of ad'I!'rst ftfr.cts of rntdiclrrions is
~ in tIderly pWftu baiM oflflK~.bitt 10 tbsort
.nd meubob mtdiutions..
obHI eldert, pltirnb for ability ID swi:rw priaf 10 .......isl!Jtian of
" tnt1iurions.
PllitnU!IIl)' r!'Iust mediartions for m.ny ff'lOns:(OSt.~ of the pill or
ublet.and Ital or pmeim:! ad'I!'IW efftm.Explort ff.lOns fo, Itfu1
,nd ti~e 'PPlOpriate !ion to ensult tht islUl' is rtSOI'I!'d (t.g., switth
from ll,uge,diffir:u~ to sWil10w pill to. smliler formuwtion).1'Id that
p.ititnt .utonomy is 1npKItd.
ExplOIt tilt p.ititnt's normal.ctirity ,nd LIIIIiI sleeping ,nd waking
houl$.Xhed,* mtd'atiom iI'OUnd thrst 1M wilen poIlille.kIcrw.s
simple a dosino !dIrd,*n pcruiblr.
~. mtdiclrrions with the pKimton rmy hOOh Uff mc.Notr
'nyCOll'lpl,lints m.rttd to sptdic drugs b ~ iI~tion.
YIIUiI dlitlgesllll)' IlliR ~tion bbrisliffir:u/t to IUd. Fo.-I\orM
adnWitrltio!'l. pIUI'idr largr-prinl itstnrr:tions,
\tile ~.~
\Md if 1WOed,.1'Id rt<omrnrnd ~ al ~tions with ltIe
PN rm.wist Nth time prescription is fiItd Mr W 1If. <o1or, and size of
the mtdir:,nion.
For It-homt urt,if stpI,ate pill (on"inm.rI' ustd othtr than tilt
original prI'scription bottle (f.'.j.,pill (onllill!'l'S divided by days of tilt
Wffij, bt Wit tilt patient, family, or <arl'1liYfr (ftlin wiginal bottles is
wtY II nOleitht color ofNch pill Should, Itaction 0(11\ I)t sltould.
miling)lOUng chid.ocm tlJe coruin morl' prtcise rtCOrd of wNt
drugs wtte poIrIrNJ, consumed wiI.id iluutirlgtllt pirifrt.
PII7iide lpe<ifir: instnKtions!of. mtdiclrrions ~ howf!tqIlel'l"'"11
~ medic.tiom ~ bt laizlr).En!Ift that the patitnt " -wNt
todo if, IMdir:IIion is bgottrn.
l1li.
"
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Many geriatrk patif nts ha\'e5eve!'al drronic medical disorders,eac:h of which may be trtated by individual spfdaliSlS.
It is rommon for these patil'llts to receive multipl e presc:riptions, sometimes for thf same oondition, that have
conflicting pharmacologic actions, a condition t~rm~d
poinrilarrucy. AlthOUgh not unique to olde!' adults,
polypharmacy is most often seen in this age group. Keeping
track of multiple medications. their doses, indic:a tions,
routes, and frequ~ncy of administration is a major challenge for both patients an d health care providers. Failurt to
properly record mediation information, and oommuniOitethat infonnation to hl'<llth Oire providers, is a potential
c:ause of medication errors.
Mtdic.atioolt(ol{iliatiorr is the process oC - keeping track" of
a patient's medications as they proceed from one health
c:are provider to another. Reconciliation ac:cur:r.tely lists all
medic:a tions a patient is taking in an attempt to reduce
duplicat ion, omissions. dosing erro rs, or drug interactions. For example, when a patient is admitted to c:are. the
nurse record s all medications the patient has been taking
at home, induding their dose, route, and frequenc:y. This
list is checked against admIssion orders and is cransrerred
to other prac:titioner s whenever the patient is moved to
different units within the hospital. It is also checked at
discharge. ThfSf - interf.. ces of cart~ are the most likely
placfS that medicat ion rfconciliation errors have bun
found to ~ur.
In 2004, lCAHO identified hundreds of SfriOU!l medication ",rors attributed to mediation reconc:iliation and dfveloped recomml'lldations for their prevention. Hospitals
are now encouraged to implement a process for doc:umenting a complete list of the patil'llt's current medic:ations upon
the patient's admission. Medications should indude prescription mooiClIio ns, ore medications, vitamins, and
herbal products. This medication list should be oommunicated to the next provider of service when a patient is referred or transferred to another setting, service, physician.
or level of art within or outside the organization. On discharge from the faci lity, provide the patient with thf rompletf list of medications [0 be takm, as weD as instructions
on how to bitt any newly prescribed medications.
H OME
& C OMMUNITY
C ONSIDERATIONS
- -
91
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92
KEY CONCEPTS
TbI.' numbered key concepts provide a suinct summary of the important points from the corresponding numbered $tion
within the dlapter. lf any of these points are DO( dear, refer to the numbered section within the chapter lOr review.
9.1
95
9.2
NumerolL'l facton cont ribute to medIcation t'rro!'$, in cluding mistakes in the five rights of drug admlnisu3tion,
failing to foU ow agency procedures or consider patient
variables, giving medications baSlid on verbal ordt'1'S, not
confirming orders that are lI1eglble or lnoomplett', and
v..arking under stressful oonditlons. Patlt'nts also con tribute to erron by using more than oDt' pharmacy, not
informing nealth ca re provlden of aU medications tht'y
art' taking, or not following Instructions.
9.6
Medication reconcil iation is an important means of reducing medication errors. Med ication reconcUlatlon Is a
process of keeping track" of I p;ltlent's medications as
tbt')' proceed from one health care provider to another.
9.7
Patient teaching indudes providing age-appropria te ntedication handouts. and enoounglng patients to keep a list
of all prescribed medications, OTC drugs, herb.,j thera_
pies, and vitamins they are taking and to report them to
all healtb care providers.
93
9.8
9A
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4.
notifythe~cian
only.
The patient wilh liver dysfunctio n experiences toxicity to
a drug following administ ra tion ofsevenJ doses. This ad verse reaction may bave been prevented If the nurse had
followed which ph ase of the nursing process!
]. Assessment
2. Planning
3. Implementation
4. Evaluation
Nurses bave a legal and moral responsibility to report med j,ation errors. The steps of !\'pOrting thcscerrorslndude:
L punishing the nurse woo commltt..'d the error.
2. monitoring umafe med ication ord ..rs.
3. identifying potential uDSolfe medication facilities.
4. examining interdisciplirlary caUSo!S of errors and
assisting profeWonais In Wll)'S to avoid mistakes.
o.,pt.'
9)
When the nurse enters the patient's room with a medication, thepatien! stateli ~ l'mon the phone,just leave my pill
on the table there." What would be the 2g response by
the nurse!
I , Leave the pill at the bedside as requested.
2. Ask the patient to leI th(' nurse know ",-hen the phone
cill ismmp1eted so that the nurse can return with the
medication.
3. Instruct the patient to either tm the medication or
refuse it.
4. Chart the medication as "una ble to give" and skip the
d"",.
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fiigl1I!IJtili(3!tI::r------,
MyNursillgM is )'WI one stop tor ani fie CIlapttr rtYIe'W matMals and
ffSOUfatS. Pr epaf8 f(J 5UCCe6I will1 a~(jtjmat t~-1lti'le practice
Quesmn~. In!/'J'&C!iI,'t ASSIgment'l tnl lClNiIIes. 'M:b 1Wls. Mlmatfons
i nc! ~. nI meI
1II!gL'Ur you' a~ CMe trom !lie fnw11 d )'GUf book at
www.mynursnglUt.c.n.
LEARNING OUTCOMES
AIrel' fMliing this coopt.." the student would be> ab/# to:
popularity.
3. Identify the parUofan herb thill may (ontain active ingredienU and
the typeS of formulations made from these parts.
KEY TERMS
MIlIIliuI J'III"'1S
(_plementir)'iIIId ilblNtM! lIlfIIi:ine{o.M)
.....
ditlllryMlppkolll'M
[JIlIJt9/J
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herb JIIlIJ''1S
CD115IIIIIl'fPre1titnAct Pl'9!I
Diftilf)' Supplelllfflf IINII~ ilnd EiMaliin Act
5p1'cial!y~ment JIIIII''If!
II mu ltibill ion-dollar industry. Sales of dieta ry supplementsaloneexceed $17 bill ion annua lly,with moreth an 158
. . . . . . Therapies
Healing Method
Examples
Naturopathy
Hom~thy
ChiropraaK
the impression that natu ral substances have more hea ling
power than synthetic medications. The ready availabi lity of
herbal supplements at a reasonable cost, combined with effective marketing strateg ies, has convinced many con-
Hrrb.J1 thrrapir5
Ilnritional !Upplrmrou
SprdIl lirts
Manual healing
Prrnu~thrr'"
Hand-lIIrchtrd bioftrklthrr~
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""
HypROlherapy
Guided imagrry
Biofffillldl
...,""
".,
Spmual
Shamans
Faithandf'1Yff
~lII'Iia
Qr,toxifying thrrapirs
Anilllillmistrd therapy
96
TABLE 10.2
",'
Herb
Medicinal Part
Herb Feature
(Chapter)
Pr1maI}'Uw(s)
(Iarb!lry
BmitsJjuic~
So
.."
Garlic
Sawl"imeno
,
,
Ginl::gt
EdJill!lU
Milt.l.iSl~
St.Joirl'IW(II\
.,.
.""
11
(')lliO'iillWar dill'u~.ln~(ill(tr
Rm~ bbxI dIoIeslmi, ItclOO' blood pr!SlU~. inliloaq.,jalion
21
Lu~and~
Erti~planl
31
Il
...,
17
FIowr~I~Slmll
"-
Roo'
lS
45
"
...
ROlli!
81
GrffiltN
".~
ProYidt antioxidant the'aP1; IIIWtr LDI.. dIoIetftOi; prt'Itnt (,)1I(tr; ~iM Ilomam
Il
Evtrir9 !limlOll'
~oil
SOUIt~ of ell'fltial
"
13
VaieM
RoolS
14
14
HomYlJGit 'IIftd
Lu~andnHIlS
"
Graptlffil9100
~oil
10
prob!tllll,naUll'l, vomlng
Souill': Ci\\l~~ C. lIu, P., LyndJ, M. E. ind 8hllltnlhal. M. {2OO9):Htrbal Supprmtnl Sale Elipffltll(e Slighl naull' in lOO8 (Unill'd StiltS I: HlrlIa./Grom Ill:S$- 61.
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PHARMFACTS
,.,
"""
Gingrrrhizome
Ginkgo lea/
Standardlzatlon
Percent
Tr~rrprne ~yIIOO
_0
""'""'"
"
PIIlgent aH!Ipooods
Gruter than 10
24-25
l/ydrol~anth~enK
RaYOgIyaJ~drs
""~.
Ginll'll9root
Ginseosidrs
lU
.-~
4<-41
Silymnin
1>-00
Hyper/orin
>-S
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0J-0.5
97
.,
~
98
TABLE 10.4
Product
Infusion
".
1ill(l!l'1'
...,
..
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Ib)
Figure 10.3
;0.
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99
100
Untl2
..
Interacts with
Comments
~ ( rOllllo:mrn,oo"Mjum)
III\U~n,OIiII Itypo9y<rmkaqenll
~~ ~ffiing nlk
Ginkgo (Ginkycbiloba)
Antitonvul!oanu
Alpinnand NSAIOI
IltplriHndwarfaril
GoIdrost~1
(I/jdrollilamildmlil)
Triqdit .nlidfpl!l!oant>
eNS~nu
~au~ Itdition
OilJOlin (Lanmrin)
~(JN~ toxicity
Oiurttiu
W;Jrf.ril
Oiurt tks
~au~ Itdation
e~ (~ndimm_)
Etwirmz. indinaYir
ProtUlt inhibitoo
ntidepr~nts
\/al""n (VlIk.mauflfd",,/i>j
Warfaril
F\IImtiot. ltdotion
Amino . rid,
Cimitilll'
"
Cotr\zyrM 01 0
II
"'"
Fish oil
Rrdutt dIoItstmll Ieoim. mhalKt' lI'ain flnaion, irm.J1t viIWI . a..ity ltlot to pl!ltntt
of OIIII'ga--l fatty adds)
II
Rrdutt ffioIroul"fOl Ieoil"k. ffihanrt' lI'ain flllnion, illITNw vkuill.nity (tloe to pR"Wntt
ofOllll'ga--lfattyaddsl
AlItoii.!tt arthritis and othtr joint probItms
lDcrobodllJil oodoplilus
~tnium
VitaminC
PrMIIlion of rokk
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"
"
101
10.1 Complementary and a1ternati'e medidne is a set of diverse therapies and healing systems used by many people
for disease prevention and self-healing.
The nurse oblains information during the admission inlerview that the patient is taking herbal supplements.
Whal implications does this information ha'e for the pa tient's trealment?
1. This is not importanl , becaust' herbal products are
natuml and pose no risk to the patient.
2. These products are a welcome adjunct to conventional
tre:ltment.
3. The nurse mU'itobserve tbe patient for allergic
reactions.
4. The herbal products may interact with prescribed
medications and affect drug action .
Appropriate teaching to provide safety for a patient who
is planning to use herbal products should include which
of the following!
1. Take the smallest amOWlI poSSIble when starting herbal
thempy, even less than the recommended dose, to see if
allergies or other adverse effects occur.
2. Read the labels to determine composition of the
product.
3. Research tbe clinical trials before using the products.
4. Read the labels to determine which diseases or disorders
the product has been proven 10 treat or cure.
The patienl states he has been using the herbal product
S,1W palmetto. The nurse recognizes that this supplement
is often used to treat:
1. insomnia.
2. urinary problems associated with prostate enlargement.
3. symptoll\<; of menopaust'.
4. urinary tract infection.
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II
~peciahy
t 02
2. A 62-year-old male p.1tlent Is re<:uperatlng from a myocardial infaraion. He is on the anticoagulant warfurin
(Coumadin) and an tidysrhythmic digoxin (lanOlin). He
talks to his wife about starting garlic to help lower his
blood lipid levels, and ginseng beocaUSl.' he has heard il
helps in coronary artery disease. DiKuss the potential con cerns about the use of garlic and ginseng by this patient.
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EXPLORE
~~'------,
PlIllar. let
SUQ;e511
a~i1ies.
....!!IIIIr*s. mimtions
wwwJllYT\Lnit!lkitcam.
Substance Abuse
DRUGS AT A GLANCE
LEARNING OUTCOMES
CANNABINOIDS [QJo!t
Marijuana P190(})
HALLUCINOGENS p /OJ
LSD
'I
Other Halludnogtns pq;Jt' 10
CNSSTIMUlANTS pogtl/()
fill"
6.
KEY TERMS
addiction {!IJgt /()j
anPlltion df:fic ivllyptr a(tivky disGrd~r (ADH DI
PJttll
brnlodia~1M fWt 101
IJOSItolMucr PIt ns
dtliritnUff'HflS (OT) /'}tIll
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rtticular fonnltion
l<'IIat~e pajt 1C1
Iubilarn:ubule
pajt 110
jllJt1()j
toi.rall(e pill}t ~
withdrawallJndromt
fXJ}t /OS
104
Untl2
Nu.....-P~iI<'nt Rel.otlomhlp
11 .2 Neurobiologic
side red more inclusive because of t he involved legal and illegal agents, misused household Items,and drugs available
tor medication pu rposes. By definition,substance a bu se in
this chapter will be considered the self-administration of a
Addict ion is an overwhelming compulsion that drives someone to take drugs repetitively, despite serious health and social consequences. It is impossible to accurately predict
whether a person will become a substance abuser. Attempts
to predict a person's addictive tende ncy using psychologic
proftles or genetic markers have largely been unsuccessful.
Substance abuse depends on multiple, complex, interacting
variables such as described in the following categories:
,"
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PHARMFACTS
probltm.
25% of high hool <tudtnlS Ust an ~J.g.1 drug monthly.
Ivl tstimmd l 4million Amtoom have ul>ell ht roin during thtir li~.
About one in fil't Americans has liffiJ with ao ikoholic: whilt growing up.
Childrtn of akoholic: p.lll'ot! all' four timts mOIl' liktly to bKorne
akoholic:s than (hild~n of nonakDholic: P'll'Ots.
Akohol is an important f<Ktor io 68% of mansLlughttr"S,54% of murdtrs,
48% of robberits, ,nd 44%ofbul9la~.
Among)'OlJthbt~otheagl'Soflland 17, 7.2 million h~druok
akohol at Imt onct.Giris wt'~ as liuly as ~ 10 drink akohol.
Baroitura~ovtrdost is a fa(lOr in almost one third of all dru!l""ll'lated
deaths.
36% of 10th-glide student! and 46%of 12th-g~t studt nts hm
Il'ported using I!Iirijuao, , nd hashish.
Almost8% ofhigh school stoiors hal't ~ported using (ouilll'.
1 million Amtriuns Mt Ustd (!luiIII' on a monthly basis;about 567,000
Me ustd (f,(k(ouint.
Approximat~ 70% of the (!luiIII' tnttring the United Stat~ rotneS from
Colombia and paslf"S thlOlHjh south Florid.!.
16% ofSth graders and 11% of 11th graders hal't ~port~ usingvolatilt
iohaLints.
30% of all Amt riuOl all'(igall'l~ltrours, in{Uding 25% who all'
bttwttn tht igtS of 11 and 25.
41% of 10th-glide studtnts and S4%of 12th-g~t studtrtts hm
'rport..! .".,kin\! <iy.,. un. 8'l(j uf 12~,-\!,.dr ,\udrn'" .,,,,,no roo",
than half a p.l(k or troll' Ndl clay.
8%of 12th-griikstudtrtll hal't Il'pOned using Eutasy (MOMAI.
I5D is oneoftht most pottntdrugt known, with only 25--150 mc:9
(onstiMing i dost.Almost 996 of 12th-gradt studtrtll hm Il'pOned
usinglSD.
CNp1IIl1
Sobnan<l',o..bu...
t 05
~ncl ~CCClrding
to
~cc.eptecl
mroic.al pmtocok A.
, '.3
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11 .4 Withdrawal Syndrome
Once a person becomes physically dependent and the substance is discontinued, withdrawal s)'lldrome may occur. Pre~
scription drugs are often used to reduce the severity of
withdrawal symptoms. For example, alcohol withdrawal
might be treated with the short-acting benzodiazepine, oxazepam (Serax); opioid withdrawal might be treated with
methadone. Symptoms of nicotine withdrawal might be relievt'd with replacement therapy in the form of nicotine
patches or chewing gum. For withdrawal from CNS stimulants, hallucinogens, marijuana, or inhalants, specific pharmacologic intervention might not be indicated.
Symptoms of withdrawal may be particularly severe for
those who are dependent on alcohol or sedatives. Because of
the severity of the symptoms, the process of withdrawal
from these agents is probably best accomplished in a substance abuse treatment facility. Examples of drugs and associated withdrawal symptoms and characteristics are shown
in Table 11.1.
With chronic substance abuse, people will often associate
use of the substance with their conditions and surroundings,
including social contacts with other users who are also taking the drug. Users tend to revert to drug-seeking behavior
when they return to the company of other substance abusers.
Counselors often enoourage users to refrain from associating
with past social contacts or having relationships with other
substance abusers to lessen the possibility for relapse. The
106
Untl2
..
Dru,
Signs ofToxldty
"
~1Lrn,delirillll
~rbitll'a~
Btnzodiaz~1\K
!4Ur.:I,
lid1yC.lfdii,~~SIOUs lI'spi"ilionl
lwitdlt!
CouilWJM
JmpMimillt!
1l.!l100n09ffil
"'-ri):Jaru
r;-OtilW
Irritability,inxitty,lI'lIIts\llesl,hurl.!dlts.iool'istdapp6~~,inlOllllia.
inabil~y
,1.S Tolerance
Tolfran(f is a biologic condition that occurs when the body
adopts to a substance after repeated administration. Over
time, higher doses of the agent are required to produce the
same initial effect. For example, at the start of pharmacotherapy,a patient may find that 2 mg of a sedative is effective for inducing sleep. After taking the medication for
several month<;, the patient notices that it takes 4 mg or perhaps 6 mg to fall asleep. De~lopment of drug tolerance is
common for substances that affect the nervous system. Toleram:e should be thought of as a natural consequence of
continued drug use and not be considered evidence of addiction or substance abuse.
Tolerance does not develop at the same rate for all actions
of a drug. For example, patients usually develop tolerance to
the nausea and vomiting produced by narcoticanalgesicsafter only a few doses. Tolerance to the mood-altering effects
of these drugs and to their ability to reduce pain develops
more slowly but eventually may be complete. On the other
hand, tolerance never develops to the drug's ability to constrict the pupils. Patients will often endure annoying side
effects of drugs, such as the sedation caused byantihistamines, if they know that tolerance to these effects will
quickly develop.
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w"
CNpttrll
11 .6 eNS Depressants
CNS dt'pressants are a group of drugs that cause patients to
feel sedated or relaxed. Drugs in this group include barbiturates, non barbiturate sedative-hypnotics, benzodiazepines, alcohol, and opioids. Although the majority of
these are legal substances, they are controUed due to their
abuse potential.
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SobnaO<l',o..bY...
107
OPIOIDS
~i ~dl, also known as lIarcotic allalgesics, are prescribed for
severe pain, persistent cough, and diarrhea. The opioid class
includes natural substances obtained from the wuipe seeds
of the poppy plant such as opium, morphine, and codeine.
Synthetic drug examples are propoxyphene (Darvon),
meperidine (Demerol), ox),codone (OxyContin), fentanyl
(Duragfsic, Sublimaze), methadone (Doiophine), and
heroin. The therapeutic effects of the opioids are discussed
in more detail in chapter 1800.
The effects of oral opioids begin within 30 minutes and
may last over a day. Parenteral forms produce immediate effeels, including the brief, intense rush of euphoria sought by
heroin addicls. Individuals experience a range of CNS effe,Is from extreme pleasure to slowed body activities and
profound sedation. Signs include constricted pupils, an increase in the pain threshold, and respiratory depression.
Overdose of opioids is extremely dangerous and fatal. The
pharmaoothel1lpy of opioid blocking drugs is covered in
chapter 1800.
Addiction to opioids can occur rapidly, and withdrawal
can produce intense symptoms. Although extremely Wl
pleasant, withdrawal from opioids is not lift' threatening,
oompared to barbiturate withdrawal. Methadone is a narcotic sometimes used to treat opioid addiction. Although
melh~done
ETHYL ALCOHOL
Ethyl alcohol, commonly known as alcohol, is one of the
most commonly abused drugs. Alcohol is a legal substance
for adults, and it is readilyavaibbleas beer, wine, and liquor.
The economic, social, and health consequences of alcohol
abuse are staggering. Despitt' the enormous negative consequences associated with long-term use, small quantities of
10 8
Unlll
Nurse-Pitlent AeL.lUomhlp
alcohol consumed on a d~ily basis have been found to reduce the risk of stroke ~nd hent att~ck.
Alcohol is classified as a eNS depre5S;lnt because it slows
the region of the brain responsible for alertness and wakethe blood-brnin barrier,so its
fulness. Alcohol easily
effects are ~rved within 5 to 30 minut es afte!' consumption. Effects of alcohol ~/'(' dirlly proportional to the
amount consumed, and include relaxation, sedation, memory impairment, 10$$ of mOl:or coordination, reduced judgment, and decreased inhibition. Alcohol also imparts a
characte!'istK odor to the breath and increases blood flow in
certain areas of the skin,causing a flushed face. pink cbeeks,
or red nose. Although these symptoms are easily recognized ,
the nurse must beaware that other substances and disorders
may cause similar efftets. For ex:.tmple, many antianxiety
agents, sedati\le$, and an tidepressants can cause drowsines.o;,
memor y diffiruities, and loss of motor coordination. Cer
tain mouthwashes contain ~lcohol and ca use the breath to
smell like alcohol. Duringasses.o;ment, the sk illed nurse must
consider these factors before confirming alcohol use.
The presen,e offood in the sto mach slows the absorption
of alcohol, thus delaying the onset of drug a,tion.
Metabolism, or detoxification of ~lcohol by the liver, occurs
at a slow, const:Jnt rate, which is not affected by the presence
of food. The average rate is about 15 mL per hour- the
practical equivalent of one alcoholic beverage per hour. If
consumed at a higher rate, akohol wiU accumulate in the
blood and produce greater depres.o;ant effects on the brain.
Acute overdoses of aloohol produce vomiting, severe hypotension, respiratory failure, and coma. Death due to alcohol poisoning is not unoommon. The nurse should teach
patients to neve!' combine aloohol consumption with other
eNS depressants because their effects are cumulative, and
profound sedition or 001Tl3 may res uh .
With acute a1oohol withdrawal. benzodiazepines are the
preferred drugdass for lTeatment (Valium or LLbrium therapy). \'/hile the use ofbelUOdiazepines is more guarded for
longer-term therapy of akoholism, the reality is that many
alcoholics continue to receive benzodiazepines (or anxiety
disorders and insomnia serondary to ruoohol dq>endence.
Seizuresarealsoa risk to the patient. even after w~b of cessation from aloohol oonsumption: hence, benzodiazepine
step-down therapy is often beneficial.
Chronic alcoholoonsumption produces both psychologic
and physiologic dependence and resullS in a large number
of ~dverse health effe,ts. Theorgan mOM affected by chronic
alcohol abuse is the liver. Akoholism is a common cause of
cirrhosis, a debilitating and often fatal failure of the liver to
perform its vital functions. Liver impairment causes abnormalities ill blood cloning and nutritional deficiencies. It also
sensitizes the patient to the effects of all medications metabolized by the liver. I=or alcoholic patients, the nurse should
begin therapy with reduced medkation doses until the adverse effects of pharmacotherapy an be assessed.
~liriumtl'@ffiHl (DT) may occ ur in individuals who have constantlyconsumed alcohol for a longer period of time. Symptoms are hallucinations, confl.lSion, disorientation , and
,rosses
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agitation. Many patients experience anxiety, panic, par.lnoia, and sensations of something craw ling on the skin.
Alcohol withdrawal syndrome is severe and may be life
threatening. Antiseizure medications may be used in the
treatment of alcohol withdrawal (dupler tSOC ). Long term treatment for alcohol abuse includes behavioral counseling and self-help groups such as Alcoholics Anonymous.
Disulfiram (Antabuse) may be given to disc:ourage rel~l'ses.
Disulfiram inhibits acetaldehyde dehydrogenase, the enzynle
that metabolizes alcohol. If a patient ,onsumes alcohol while
taking disulfiram, he or she bemmes violently ill within 5 to
10 minutes, with headache, shortness of breath, nausea!
wmiting, and other unpleasant symptonu. Disulfiram is effe.::tiveonlyin highly motivated patients,sin,e the success of
pharmacothe!'apy is entirely dependent on patient oompliance. Alcohol sensitivilf continues for up to 2 weeks after
disulfiram has been discontinued. As a pregnancy ategory X
drug, disulfiram shou ld neve!' be Imn during pregnancy.
In addition to disulfiram, ao;amprosate akium (Campral, I=orest) is an FDA.approved d.rug for maintaining alcohol abstinence in patients with alcohol dependence. Studies
comparing the therapeutic benefit of disulfiram with aat mprosat~ have not b.oen fully d~ mo~tratN. nl~ drug mOlY
benefit patients who are not candidates for naltre.'tOnt therapy. (Patients receiving naltrexone therapy or patients re ceiving methadone treatment are subject to withdrawal
symptoms. ) Acamprosate's mtehanism of action im'olves
the restoration of neuronal excitation-the alteration of
gammaaminobutyratt' and glutamate activity in the
CNS---and does not appear to have other central nervous
system actions. Adverse reactions to acamprosate include
diarrhea, flatulence, and nausea. The drug is contraindicated in patients with seve!'e renal impairment but may be
used in patients at increased risk for hepatoto:cidty.
" .7 Cannabinoids
Cannabinoids are substances obtained from the hemp plant
CAnnabis sa.iva, which thrives in tropical climates.
Cannabinoid agents are usually smoked and include mari-
Choptflll
109
MARIJUANA
11.8 Hallucinogens
LSD
For nearly all drugs of abuse, predictable symptoffi'i occur in
/H,, - CH.
C- N
CH. - CH.
OP(OH),
CH,
I
W-CH.-
CH, - N(CH.l.
,
I
Ps ilocybin
(4-phosphoryl-OMn
LSD
Flgu~ 11.1 Comparison of the chemical structures of psllocybln and LSD. Psilocybin (left) Is derived from a mushroom
So!.v"c e: )ames BlNf!rldijeNlsua/s lt1i!m!red.
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11 0
Mescali ne
11 .9 eNS Stimulants
OTHER HAllUCINOGENS
In addition to LSD, olher abused hallucinogens include the
following:
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CNplfr II
COCAINE
Cocaine is a natural substance obtained from leaves of the
ooca plant, which JIIOws in the Andes Mountains region of
South America. Docwnentation suggests that the plant has
been used by Andean cultures since 2500 B.G. Natives in this
region chew the coca leaves, or make teas of the dried leaves.
Becausecoca is taken orally, absorption isslow,and the leaves
oontain only 1% cocaine, so users do not suffer the ill effects
caused by chemically pure extracts from the plant. In the Andean culture, use of coca leaves is not considered substance
abuse because it is part of the social norms of that society.
Cocaine is a Schedule II drug that produces actiolts similar to those of the amphetamines, although its effects are
usually more rapid and intense. It is the second most commonly abused illicit drug in the United States. Routes of administration include snorting, smoking, and injecting. In
small doses, cocaine produces feelings of intense euphoria,
a decrease in hunger, analgesia, illusions of physical
strength, and increased sensory perception. Larger doses
will magnify these effects and also cause rnpid heartbeat,
sweating, dilation of the pupils, and an elevated body ternperature.After the fe~lings of euphoria diminish, the user is
left with a sense of irritability, insomnia, dep ression, and extreme distrust. Some users report the sensation that insects
are crawling WIder the skin. Users who snort cocaine develop a chronic rWIny nose, a crusty redness aroWId the
nostrils, and deterioration of the nasal cartilage. Overdose
can result in dysrhythmias, convulsions, stroke, or death due
to respirntory arrest. The withdrawal syndrome for amphetamines and cocaine is much less intense than from alcohol
or barbiturate abuse.
CAFFEINE
Caffeine is a natural substance found in the seeds, leaves, or
fruits of more than 63 plant species throughout the world.
Significant amounts of caffeine are consumed in chocolate,
coffee, tea, soft drink>, and ice cream. Caffeine is sometimes
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111
added to OTC pain relievers because it has been shown to increase the effectiveness of these medications. Caffeine travels to almost all parts of the body after ingestion, and several
hou", ar~ u"t:<.It:<.I [or th" l.>oUy to ",,,talmliL,, auu dimiuat"
the drug. Caffeine has a pronoWlced diuretic effect.
Caffeine is considered a CNS stimulant because it produces
increased mental alertness, restlessness, nervousness, irritability,and insonmia. The physical effects of caffeine include
broru:hodilation, increased blood pressure, increased production of stomach acid, and changes in blood glucose levels. Repeated use of caffeine may result in physical dependence and
tolerance. \'/ithdrawal symptoms include headaches, fatigue,
depression, and impaired perfomlance of daily activities.
11.10 Nicotine
Nicotine is sometimes considered a CNS stimulant, and although it does increase alertness, its actions and long-term
consoquences place it in a class by itself. Niootine is unique
among abused substances in that it is legal, stronglyaddictive, and highly carcinogenic. Furthermore, use of tobacco
can cause harmful effects to those in the immediate area
who breathe secondhand smoke. Patients often do not consider tobacco use as substance abuse.
11 2
The iKidencr of tobai:oo 1M 'am among riIWl .nd tthnic: groups. The hig~t
ra~ ~among Ameri<an Inciam i nd AIasb Natim.Afri:an Americans al!o~ i
hMjl Pf".m olvnoking.~ kIwrIt PIM~lKf ~ imong Alian American and
Hiijlanic: womm. Of paMmar ((I!)(f!n is tilt 1M 01 oHhomising by the tobao indUllry to targtt !pKifK agt Of ethnic: glOJps thrrugh mrming in magalintS
publilhedfor~ifK fthnicgroups DrOll Idta tebilion WrM.
SmokiIg and other tobHoo !Ill aft' major contributors of tilt thrfl' itading
QUItS of d9th iI African Americans- lltan dilt3ll', UIK~ and , . A!ritan
American men art at lealt SO% IIIOft' ~u~ to rIMIop king call(ff than Wh~
mtn.(~broyuaMr diltall' ~!Wier as hMjl amongAfric:anAmfflcan men {ompoalfd with White men.Afri:.n Amfflcan women do oot lart any bettff: The incidenuolltrokes illW~asligharnong Afric:an.o\rnfflc:anwomenasamongWh~
women. Nul>eS moukl mate thti" ethni!aly d~ paOOm, poartiruLllfy
African Arnerians.. bout ther iKrtoud riskof.wall'.nd ft'{ommend ming
(esation programs.
nicotine replacement patches and gum assist patients in deal ing with the unpleasant withdrawal symptoms, only 25% of
patients who attempt to stop smoking remain tobacco-free a
year later.
KEY CONCEPTS
The numbered kq conrepts provide a succinct summary of th .. important points from the corresponding numbered section
within the chapter. If any of these points are not clear, refer to the nWllbered section within the chapter for review.
11 .1 A wide variety of substances may be abused by individuals. All of these substances share th .. common characteristic of alterin g brain physiology and/or perreption.
III Addiction is an overwhelming compulsion to continue re-
peated drug use that has both nt'Urobiologic and psychosocial components.
113 Certain substanCf'S can calise both physical and psychologic dependence, which result in continued drug-seeking
behavior despite negative health and social consequences.
11.4 The withdrawal syndrome is a set of uncomfortable
symptoms that occur when an abused substance is no
longer available. The severity of the withdrawal syndrome
varies among the different drug classes.
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11.5 Tolerance is a biologic condition that ocrurs with repeated use of certain substances, and results in the necessity for higher doses to achieve the same initial response.
Cross-tolerance occurs between closely related drugs.
11.6 CNS depressants, which include sedatives, opioids, and
ethyl alcohol, decrease the activity of the brain, causing
drowsiness, slowed speech. and diminished motor coordination.
11 .7 Cannabinoids, which include marijuana, are the most
frequently abused class of illegal substances. They cause
less physical dependence and tolerance than the CNS
depressants.
CNpUI" II
SUb"."", Abu,,,
113
11 .10 Nicotine is a powerful and highly addicti"e cardiovascular and CNS stimulant that has serious adverse effects
with chronic use.
11 .9 CNS stimulants-induding amphetamines, methylpheni date, caffeine, and cocaine--increase the activity of the CNS
and produce tncreased w.tkefulness.
4. Marijuana
Th<' p"ticnt with a history of alcohol abuse is admitted to
the hospital. The nursing cu e plan includes assessment of
the patient for which of the following symptoms indicative of alcohol withdrawal?
]. Mental depression, headaches, and hunger
2. IllSOnmia, nausea, and bradycardia
3. Tremors, hallucinations, and delirium
4. Weakness, hypotension, and violent yawning
II
1:1
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2. Thewifeof a 24-year-old professional football player isadmilled to the emergency room after being beaten and ver
bally abused by her husband. She says that he is under a
great deal of stress and has been working hard to maintain
peak athletic fitness. She says she has noticed that her hus.band becomes irritable easily. What assessments and interventions should the nurse perform!
11 4
UnII2
PNo'~ology
1, A 44-year-old bushll'SSman travels weekly for 1115 romp<l lIy and has h.ad difficulty skeping in MOlle hotel aft~r another: He oonsultNl his health care provider and lias been
taking secobarbital (Seoonal) nightly to help him skep.
The p<ltlent lias ,ailed the nurse at the healtll .;are
provider's offke and has said, . , ha."". just got 10 have
someth ing Sl ronger: What does the nurse consider as plrt
of the assessment!
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EXPLORE
Liij;llI!Iftfflng!ft::r------,
hl:fl'trrsinSKit 15
y(lUJ
~ ~
ma1eItIls IIld
Emergency Preparedness
and Poisonings
LEARNING OUTCOMES
After readinf} this chapter, the student should be able to:
1. Explain why drugs are Important In the context of emergency
prep&redness.
2. Discuss the role of the nurse In preparing for and responding to a
bioterrorist act.
1. Identify the purpose and components of the Strategic National
Stockpile (SNS).
4. Explain thll threat of anthrax contOlminalion and how It is transmitted.
5. Discuss the clinical manifestations and treatment of anthrax exposure.
KEY TERMS
actiYated rnarroal poqt III
acute radiation s)'Ildromr pu;t I}()
anthral fX1}t 118
bil5icsupporti'ft' care pajt 1]1
bioterrori!ilT1 paqt 116
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Syrupoflpr!cac {JOl}tlll
vaccine {XljO 19
vmdormanaged innntory (YMI) {Xljt 118
whole-bowel irrigation pq III
11 6
TABLE 12.1
DIsease
PHARMFACTS
Target
hn~nza
IiMmDphiIuf ill1lwfllM
Rt5piratoryl)'lll'll1
17
T!btn:ulosis
Mywooatrium rubmlosis
""ffi
'fibricrhoJtfUl'
"""
Oigfsti',or, UK!
I.'
I.S
Immolll' ~5p(m~
l.l
AI.
Miltaria
"',,'"
IItpititis B
Whooping (oujl
Tmnus
OengUl'ffflf
6tooddisortltr
'.S
Rubtola l'irus
L!IIgsand mtningts
0.%
IItpititis hM (H8V)
"'"
0.""
~r.ltOl")'IYIi~m
0.41
o.m
Enti~ body
0.1 4
Son/ertlloperllJl5is
I OusDidum m.ID
Ral'iviM
(fe'ml
Soultt: .kJ1y 2001 rtpor1 by th~ WIIOlindUllry Drug DMIopmtnt Working Group- WOOd Health ()garization: http:/,w-.who.int/en1
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or no specialized knowledge to disseminate. Areas of greatest concern include acutely infectious diseases such as anthrax, smallpox, plague, and hemorrhagic viruses;
incapacitating chemicals such as nerve gas, cyanide, and
chlorinated agents; and nuclear and radiation emergencies.
The CDC has categorized the biologic threats, based on their
potential impact on public health, as shown in Table 12.2.
In 2001 1CAHO issued new standards that shifted the focus from disaster preparedness to emergency management.
The newer standards included more than just responding to
the immediate casualties caused bya disaster, they also considered how an agency's health care delivery system might
change during a crisis, and how it might return to normal
operations following the incident. The expanded focus also
included how the individual health care agency would coordinate its efforts with community resources, such as other
hospitals and public health agencies. State and federal agencies revised their emergency preparedness guidelines in an
attempt to plan more rationally for a range of disasters including possible bioterrorist acts.
Planning for bioterrorist acts requires dose cooperation
among all the different health care professionals. Nurses are
central to the effort. Because a bioterrorist incident may occur in any community without warning, nurses must be
prepared to respond immediately. The following elements
underscore the key roles of nurses in meeting the challenges
of a potential bioterrorist event:
Descrtptton
EXllmples
Agtnl> thilt:tan t~ ~Iy lit diSlminalrd or tr.Inlm~lrd pmon 10 person; (,JIM hi91
mortall1, with poIt nlial for m,p" poJIIic htakh impaa; rrighl (,JIM]I\tIIi( panic ,nd
social Ihruption; or rt!pire !pfdaI action for public htallh prt~dlltSl
Agtnl> thilt:are modffilltly til)' 10 dilsffilinatt; catrlt lI"IOdtratt morbidly and low
mortally; Of requll' spffiti( mnc:mlffill of (1)('\ diagl105IK (,Jpadty ,nd mlwlK td
mlNlt IlrlrillalKt
Vir,1 ffiltphallis
Waln-liftty IlRallludJ 011 V.modrolfflleand
C!~dium ponum
(
Hantavirul6
MutKtug-rristanl1Ubfflulosi I
Nipah Vlus [NiYJ
fld.-bomr ffiI~I~1 vi'ul6
Ydowfl>oltr
SouA?hllp:l/Www.bl.k.9O'I'~iCjtntlist-<ittgOlY.alp
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11 8
Untl2
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The stockpiling of antibiotics and vaccines by local hospitals, clinics, or individuals for the purpose of preparing
for a bioterrorist act is not recommended. Pharmaceuticals have a fmite expiration date, and keeping large stores
of drugs can be costly. Furthermore, stockpiling could
cause drug shortages and prevent the delivery of these
pharmaceuticals to communities where they may be
needed most.
12.4 Anthrax
One of the first threats following the terrorist attacks on the
World Trade Centerwasanthral.ln the fall of2001,five people
died as a result of exposure to anthrax, presumably due to
purposeful, bioterrorist actions. At least 13 U.S. citizens were
infected, several governmental empl~s were threatened,
and the U.S. Postal Service was interrupted for several weeks.
There was initial concern that anthrax outbreaks might disrupt manyother essential operations throughout the OOWltry.
Anthrax is caused by the bacteriwn Bacillus anthracis,
which norn,aUy affects domestic and wild animals. A wid"
variety of hoofed animals are affected by the disease, induding cattle, sheep, goats, horses, donkeys, pigs, American bison, antelopes, elephants, and lions. If transmitted to hwnans
by exposure to an open wound, through contaminated food,
or by inhalation, B. aruhmds can cause serious damage to
booy tissues. Symptoms of anthrax infection usually appear
1 to 6 days after e."l:posure. Dependingon how the bacterium
is transmitted, specific types of anthrax "poisoning" may be
observed, each characterized by hallmark symptoms. Clinical manifestations of anthrax are sUllUllariz.ed in Table 12.3.
B. aruhracis causes disease by the emission of two types of
toxins, edema toxin and lethal toxin. These toxins cause
necrosis and accwnulation of exudate, which produces
pain, swelling, and restriction of activity, the general symptoms associated with almost every form of anthrax. Another
component, the aruhrax binding receptor, allows the bacterium to bind to human cells and act as a "doorway for
both types of toxins to enter.
Further ensuring its chance for spreading, B. aruhracis is
spore forming. Anthrax spores can remain viable in soil for
hWldreds, and perhaps thousands, of years. Anthrax spores
are resistant to drying, heat, and some harsh chemicals.
ll,,,,,~ 'pur .... an, lh~ ",aill ~au,~ fur puuliL ],,,altl, ~U"L~rll,
because they are responsible for producing inhalation anthrax, the most dangerous form of the disease. After entry
into the lungs, B. anthmcis spores are ingested by
macrophages and carried to lymphoid tissue, resulting in
tissue necrosis, swelling, and hemorrhage. One of the main
body areas affected is the mediastinum, which is a potential
Gistroinl61inalanllnl
Dl&r1ptlon
Symptoms
Sma' skin Itsions rIMIop and lum inlO btidllabs; ilHllWt OIl
lam I6s than 1Wffk; uonol lit spmld by ptrsoMU.ptIIOI
<0000
usualymt~l
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with anthrax, military personnel deployed to high-lisk areas, and those who deal with animal products imported
from areas with a high incidence of the disease.
There is an ongoing controversy regarding the safety of
the anthrax vaccine and whether it is truly effective in preventing the disease. Until these issues are resolved, the use of
anthrax immUilization will likely remain limited to select
groups. Vaccines and the immUile response are discussed in
more detail in chapter 3ZOO.
"
'2.S Viruses
In 2002, the public wasastounded as researchers annoUilced
that they had "builCa poliovirus, a threat that U.S. health officials thought had essentially been eI"3dicated in 1994. Although virtually eliminated in the Western Henlisphere,
polio was reported in at least 27 countries as late as 1998.
The infection persists among infants and children in areas
withcontaminated drinking water or food, mainly in underdeveloped regions of India. Pakistan, Afghanistan, western
and central Africa, and the Dominican Republic. In the
United States, polio remains a potential threat in I of
300,000 to 500,000 patients who are vaccinated with the oral
poliovirus vaccine.
The current concern is that bioterrorists will culture the
poliovirus and release it into regions where people ruave not
been vaccinated. An even more dangerous threat is that a
mutated strain, for which there is no effective vaccine. might
be developed. Because the genetic code of the poliovirus is
small (a round 7,500 base pairs), it can be manufactured in
a relatively simple laboratory. Once the virus is isolated,
hundreds of different mutant strains could be produced in
a very short time.
In addition to polio, smallpox is considered a potential
biohazard. Once thought to have been eradicated from the
planet in the 1970s, the variola virus that causes this disease
has been harbored in research labs in several coWltries.
Much of its genetic code (2 00,000 base pairs) has been sequenced and is public infornJation. The disease is spread
person to person as an aerosol ordropletsor bycontacl with
contaminated objects such as clothing or bedding. Only a
few "ira] particles are needed to cause infection. If the virus
is released into an unvaccinated population, as manyas one
in three people could die.
,
9
1 20
Untl2
There are no effective therapies for treating patients infected by most types of viruses that could be used in a bioterrorist attack. For some viruses, however, it is possible to create
a vaccine that could stimulate the bodys immWle system in a
manner that could be remembered at a later date. In the case
of smallpox, a stockpile of the vaccine e.mts in enough quantity to administer to every person in the United States. The
variola vaccine provides a high level of protection if given
prior to exposure, or u p to 3 days later. Protection may last
from 3 to 5 years. The following are contraindications to receiving the smallpox vaccine, Wlless the individual has confirmed face-to-face COlllact with an infC\."ted patient:
Persons with (or a history of) atopic dermatitis or eC"Lema
Persons with acute, active, or exfoliative skin conditions
Persons with altered immWle states (e.g., HIV,AIDS,
leukemia, lymphoma, immunosuppressive drugs)
signs of exposure to nerve gas agents relate to overstimulation by the neurotransmitter acetylcholine (Ach) at both
central and peripheral sites located throughout the body.
Acetylcholine is normally degl1lded by the enzyme acetylcholinesterase (AchE) in the synaptic space. Nerve agents
block AchE, increasing the action of acetylcholine in the
synaptic space; therefore, all symptoms of nerve gas exposure
such as salivation, increased sweating, muscle twitching, invollUltary urination and defecation, confusion, convulsions,
and death are the direct result of Ach overstimulation. To
remedy this condition, nerve agent antidote and Mark I injector kit.. that contain the anticholinergic drug atropine ora related medication are available in cases where nerve agent
release is expected. Atropine blocks the allaciunent of Ach to
receptor sites and prevents the overstimulation caused by the
nerve agent. Neurotransmitters, synapses, and autonomic receptors are discussed in detail in chapter lJOO.
12.6 ToxicChemicals
Although chemical warfare agents have bet>n available since
\Vorld \Var I, medicine has produced few drug antidotes.
Many trrotments provide minin131 help other than to relieve
some symptoms and provide comfort following exposure.
Most chemical agents used in warfare were created to cause
mass casualties; others were designed to cause so much discomfort that soldiers would be too weak to continue fighting.
Potential chemicals that could be used in a terrorist act in clude nerve gases, blood agents, choking and vomiting
"H"," ls, amI lhu, ... lhal UlU' ... '~v<:r... [,ml ... ri"g. Ta['l~ 12.4 1''''vides a summary of selected chemical agents and known an
tidotes for chemical warfare and first-aid treatments.
The chemical category of main pharmacologic significance is nern ag~nu. Exposure to these acutely toxic chemicals can cause convulsions and loss of consciousness within
seconds, and respiratory failure within minutes. Almost all
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Signs of Discomfort/Fatality
AntldoteS/Flrst Aid
FkIsh ryfi and IIIaIh skin with Wit er. Fa" inhalation 01 mist.
oxygerl and amyl nilrite may III' gil'l'n.For ingestioo 01 cyarilk
liqJid. 1% mum tliosulfatt may be!j'/fll to indlKe vomilirl9.
NERVE AGENTS
GA- Tibun(liquid)
GB- Sarin (ga~ liquid)
GO-Somin (liqJidl
VX(ga\f(llJ\ lquid)
BLDOD AGENTS
CHOKING/VOMITING AGENTS
Pho~(gas)
"om
Adimsitt--DM (ay5lamlll' dsptnstd
inOoffilsol)
BLiSTER/VESICANT AGENTS
Pho~ oxillll' (aystillilt or ~q!id)
MU5laId- ltwisitt
MilI!R- fU
".
-.
SouI!t:Chemic:a1 Fia Sheets at the U.S.,l.rmy (enttr for Htalth Promotion ind PtMII~~ Mediolll' wtbs~t: hl1p:l/mwm-www.ipgta ..umy.miVdll/dKhnnIs.htm
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1 22
UrdU
TABLE 11.S
Substance
Number
""r(rotagE'
...
184,906
11.9
214,700
214,091
Sediti'le-frfpootil:!/illipsydlolia
1(1,lSO
Fomgn boIR!/IO'f"miK~lant(IIJI
120,m
m,m
"
"I.'
I.'
...
Topkal ~ljlloos
105,308
'.1.
Ptstidd!1
%.811
Antideprl's~nlS
95,317
Bit!1and l"II'IffiOI1\itiom
82,lll
14
CardiO'.'a\(wr~
,,-
80,416
13
11
Antilillamint\
76,531
75,07(1
66,115
1.'
Antiniuobiais
11
6,017
1.7
M.'
"
63,331
1.'
51,875
1.1
Gastrointrstinal p~ratioo!
50,914
1.1
49,516
1.1
Chtmic.Jis
47,557
46.139
I.'
I..
PianlS
'fmmim
"--
1.7
Antitol"MNnlS
40.476
L7
FUIIItS/gal!1i'1apoo
39,586
I.,
o\ruImftslctrn """,,,its
37,990
I..'
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Produ(\ Name
oKltylqSlNll
M!Kom)'Sl
aUopine 5UHatl
uk:i!lll !OrA
defrroxirrine
Df:sltral
digoJ:inimmllM fab
Digibind
OigoQn;dqtoxin (uldi.KglytOlidli
diMruproi
BALinOiI
ftumurnil
fornepizoll
......
....
ltIKa.'om
r.oo!tigmn.
....
Anlizoll
ImUin (h)'p:>g~tflllgl
WdklWorin
~~"
Pro.in
ptneIratl lin(\rilOdium
Pffiidliamint
~igmint
Cuprimn.. Dtpffi
Ant~iriJm
potmi!llliodrlt
pralidoxime
protarrine 5lA/atl
prusManbhr
IlKOIlll'l
vitamin K
poiIonilg)
Pm.....
--
RadiogardiSl'
KEY CONCEPTS
The numbered kt'y conCt'pts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not clear. ref",r to the numbered section within the chapter for review.
12.1 Bioterro rism is the deliberate use of a biologic or physical
agt'nt to cause panic and mass casualties. The health as-pt'Cts of biologic and chemical ag<'llts have become important public issues.
12.2 Nurses play key roles in emergt'ncy preparedness, includ ing providing education, resources, diagnosis and treatment, and planning.
12.] Th", Strategic National Stockpile {SNS} is used to rapidly
deploy medical nec:essities to communities experiencing a
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1 24
Untl2
12.8 Among human poison exposures, common pharmaco logic agents are at the top of the list. The nurse must be fa miliar with fundamental elements of toxicity treatmt'nt:
basic supportivt' measures, Syrup of Ipecac, gastric lavage
and aspiration, activated charcoal, whole-bowel irriga tion, and specific antidotes_
3. Ciprofloxacin (Cipro)
4. Smallpox vaccine
II
1:1
Nurses playa key role in tht'event of a potential bioterrorist attack including: (Select all that apply. )
1. helping to plan and de'\o-elop emergrncy management
4. He\tdache
5. Cough and dyspnea
Potassium iodine (KI) takt'n immediatt'ly foUowing a nu clear incidt'nt can prevent 100% of radioacth-e iodine
from t'ntering which body organ?
1. Brain
2. Thyroid
3. Kidnt')'
4. liVl'T
plm'
2. recognizjng and reporting signs and symptoms of
chemical or biologic agent exposure, and assisting with
treatment
3. storingantidOles, antibiotics, vaccines, and supplies in
thcir homes.
4. keeping a list of resources such as health and law
enforcement agencies and other contacts who ..uuld
assist in the event of a bioterrorist attack.
5. keeping up-to-date on emergency management
protocol and 'Ulunteering to become Illt'mbersof a
first -response team.
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EXPLORE
fiij"ll!lifing!tlJ------,
MyNursil1 gM is )'011"
~rQjs.
0Il~
SlOp fur
o nl,,)~
chapter
r1!vi~
materialS and
..-:tiItm""". wm
link . I""'Tlm.
Regi ster )OOt oc ce~ moe !rom 1he IfMl ~ \'OIlr IlOOJ< 81
...-.myn..-.-.gkit clII1I .
UN I T
The Nervous
System
CHAPTER 13
CHAPTER 14
CHAPTER 15
CHAPTER 16
CHAPTER 17
CHAPTER 18
CHAPTER 19
CHAPTER 10
CHAPTER 21
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DRUGS AT A GLANCE
LEARNING OUTCOMES
ADRENERGICAGENTS(SYMPATHOMIMHICS)
""ou
AORENERGI(-BlOCXINGAGENTS /X'iIt1J6
Go) promsln (Mllllprf!!ss) (XJIJf IJl
CHOLI NERGICAGENTS
(PARASYMPATHOMIMETlCS)
(XJIJf
116
Direct-Acting Pal1lsympathomimetia
Q
""]9
"",~
(ANTICHOlINERGICS)
pilI/tl40
"" ,.
KEY TERMS
H~tyk:hol int(Ach)
(holintrgic
paJ019
(XJIJf IJ1
ntidMllinergic
(XJIJf IJ1
pi1//t III
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fIIX}t IJI
ptXJt I}I}
127
The nervous system has two major divisions: the central nero
YOussystem{CNS) and the peripheral nerYOussystem. The CNS consists of the brain and spinal cord. The peripheral nervous
system consists of all nervous tissue outside the CNS, including sensory and motor neurons. The basic functions of
the nervous system are as follows:
Autonomic drugs are important because they mimic Involundrugs is essential to the treatment of disorders affecting many
body systems, induding abnormalities in heart rate and
Bra in
(rece;_ and processes
sensory infonnlllion;
in~ialBs ... sponsos;
.\0",. memorie.;
gene ",'e. thoo.9>ts
and e motiOM)
Sp ine l Cord
(conduct. si gnals \0 and
from the brain; controls
...tIM ItCiMties)
Motor tieu'one
(carry signals from the
CNS that control the
aclMt",s 01 """"""s
a nd glancb)
Senaory Neurons
(carry oignaLs 10
Ihe CNS from
"""SO'Yorgans)
j
Somatic Nervou s System
'''''kul~ M "" hfly
""""""",Is by ac:tiwIing
skeletal rnJSCIes)
Sympathetic Division
(prepare. the body for
stressful or _rgalic
aclMty; 'light or flighr)
Pa",sympathetic Division
(dominates dumg ~ "",s 01
"rest and digestion";
dirocta maintonance I>CIMtiH )
I
Ad .... ".,rgic ReceplDtS
....
j
I
~
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...
Cholinergic Receptors
128
Unlll "TheNelvoo.Sy.tem
branches of the autonomic nervous system. The major actions of the two divisions are shown in ~ Figure 13.2.lt isessential that the student learn these general regulatory
actions early in the study of pharmacology, because knowledge of autonomic effects is helpful to predict the actions
and side effects of many drugs.
The sympathrticnerYoullystem is activated under conditions
of stress, and produces a set of actions called the fight orflight
~sponse. Activation of this system will ready the body for an
immediate response to a potential threat. The heart rate and
blood pressure increase,and more blood is shunted toskeletal muscles. The liver immediately produces more glucose
for energy. The bronchi dilate to allow more air into the
lungs, and the pupils dilate for better vision.
Conversely, the parasympatheticnrrvoussystem is activated under nonstressful conditions and produces symptoms called
the Ifttanddigest Iftponse. Digestive processes are promoted,
PARASYMPATliETIC
DIVISION
rest lind digllst
SYMPATHETIC
DIVISION
"fight DO" 119>1'"
constricts
dilatas pupil
",,'
stimJlat....
salivation
inhibOls
saivation
constricts
btonchi""'"
dilates
bronchioles
stimulates
digeslion
inhibOls
digestion
stimJlales
gallbladd."
.ti..uates
rela a .... at
...., {
~-
'~H
sea.. t....
"";.-...phri"" and
norepi.-...phri""
conl ...ct.
.. ...
stimulates
sox of9lln5
inhibOls &Ox
organs
..
""'"
~.
". Figure 13.1 Effects of the sympathetic and parasympathetic nervous systems
Source: BIology: A Gukle to the NatlJral World,2nd ed. (p. 558) oy David K1~, 2001. Upper Saddle RIver, NJ, Prenfke H111. Reprinted IIy pennlllkJn.
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OIoplfl 11
The dassic smdy of drugs affecting autonomic function centers around the last two mechanisms. It is important for the
student to understand that autonomicdnrgsare not given to
correct physiologic defects in the autonomic nervous system. Compared with other body systems, the autonomic
nervous system itself has remarkably little disease. Rather,
drugs are used to stimulate or inhibit target organs of the au
tonomic nervous system, such as the heart, lungs, glands, or
digestive tract. \Vith few exceptions, the disorder lies in the
target organ, not the autonomic nervous system. Thus, when
an Rautonomic drug" such as norepinephrine (Levarterenol,
Levophed) is administered, it does not correct an autonomic
disorder; it corrects dysfWlction of that target organ naturally stimulated by the autonomic neurotransmitter.
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129
angliook: neuron
and heart rate and blood pressure decline. Not as much air
is needed, so the bronchi constrict. Generally, most of the
13.4 Norepinephrine
and Acetylcholine
The two primary neurotrafl'lmitters of the autonomic nervous system are nOl!pinrphrinr (NE) and acetylcholin r (Ac:hl. A detailed knowledge of the underlying physiology of these
neurotransmitters is required for proper understanding of
drug action. When reading the following sections, the student should refer to the sites of acetylcholine and norepinephrine action shown in ~ Figure 13.4.
': J?"I
.,.,.,..
Ganglionc
PostgangIionk: neuIOn
--
Target
130
Unlll TheNelv"",.Sy.tem
Sympathetic pathway
Aen
\
h-
Cholinergic
,eceplo, (nicotinic)
;I~
Adrenergic
po.tganglionje
"""
-~
Ach
\
l~...}
ChoI;""rgic
preganglionic
Autonomic
synapse
~~
ChoIi""rgic
Ach
"'ceptor (nicotinic) \
I
ChoI;nergic
post9anglionje
/ChoIiMrgiC
"~~f
(::c)
Targel
tiSSUII
~'oo
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IlIop1fl 11
13 1
oK~tykhoIiIt (moli~1
........,,
'rn,
Primary Locations
ResponSE's
'rn,
Intibilion of lnIOOIh ~
Nicotinio:
fbIIlJin9ioriulturOlll
Musurinic:
H",
Receptor
(chapter 2(00 ). Dopamine receptors in the peripheral nervous system are located in the arterioles of the kidney and
other viscera. Although these receptors likely ha~ a role in
autonomic fWlction, their therapeutic importance has yet to
be fullydisoovered.
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1fmIi0lll
discovered that these actions closely resemble those produced when a patient ingests the poisonous mushroom
Amanita muscaria. Because of this similarity, these Ach receptors were named rnulrarink receptors. Unlike the nicotinic
receptors, which havt' few pharmacologic applications,
muscarinic receptors art' affected by a number of medications,and these are discussed in subsequent sections of this
chapter.
The physiology of acetykholint' affords several mechanisms by which drugs may act. Acetylcholine is synthesized in the presynaptic nerve tt'rminal from choline and
acetyl coenzyme A. Once synthesized,Ach is stored in vesicles in the presynaptic neuron. \'/b.en an action potential
=c.b.es the nerYe ending, Ach is released into the syn~ptic
cleft, where it diffuses across to find nicotinic or muscarinic receptors. Ach in the synaptic cleft is rapidly destroyed by the enzyme atftyirnolinestrrne(khE), and choline
is reused. The choline is taken up by the presynaptic neuron to make more Ach, and the cycle is repeated. Drugs
can affect tht' formation, release, receptor activation, or
destruction of Ach.
AUTONOMIC DRUGS
13.6 Classification and Naming
of Autonomic Drugs
Given theoppositt'actionsofthe sympathetic and parasympathetic nervous systems, autonomic drugs are classified
based on on .. of four pOMibl.. action...
132
Until TheNelv"",.Sy.tem
.....
Prtmary USE'
Bm,
doridilt (C,uapre)
Alp/IJ, in CHS
Hyptntn~on
dexmtdetornidM HO (PrradeJ:)
Alp/IJ, in CHS
Sfdation
dobutamiM (Dobutrrx)
Bm,
urdiK !limUafl
doparniot(lntr~n)
'M
urdiK arret.a!ltlni
fonnottrol (Foradin
Bm,
Asthrru, COPD
iIoprot~(~)
B6.l,aod~li,
IIII'taproltfl'OOl (Alupmt)
Bm,
IIII'taraminoi (AramilH')
IIII'th)'l~
....
........
(Aldorntl)
rnidodriot (ProAmatiot)
lIOfl'PiotPlrilr (~a1ermol, u,YOphrd)
OI)'rtJetlloline (A/rin aod olhrrs)
Q
phenyltphrilH' (Hro-S)'IItItlrilH')
Alp/IJ, in CHS
AIp/IJ ald ~ta,
........
Hyptntn~on
Hyptlttn~on
'M
tQ5aI (ongtItion
1Q5aI (ongtItion
1Q5aI ror.getion
rittdiot(Yutopu)
Bm,
Bm,
Bm,
lilrntlmll (5trMllt)
tffloutalilH' (BlI'thiot aod otllm)
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.....
OttongeSlifl
IlIoplfl 13
Ne,,,,,,,, SY'lem
1n
B~~au,,,
Drug
InWnaSil Administrilion:
~ i11ri1n.!1ily
oollop!,
ronllridilgsmall ~ 'IM'Is i1 1M
"",m~
Topi:~1
Administr ilion:
mminalionl, p/II'n)Wphrine
Pa_
tope-ally to 1M f~
1M pupl without (~U!ilg !MJVfiunt
p/IfnyIfphrilt
~at
OOIeI.II!!oogfr dur.ltioo
silJjfiunt
~
PJin~ine
ADMINISTRATION ALERTS
Parentt ral ~dministr.ltion (an (~use tisMl~ injury with rxtrav.llition.
Phenyltphrifl!' ophthalmic: drops fIIiIy dafllilgt soft (OIIUct It~.
PrrgnilK)'utegory(
PHARMACOKINETICS
Onll"t: ImmNiat~ 10- 15 min IM/suiKuuneous
~k : 5-10 min IV; 15- 10 min IV/MliKUlantoUl
Halflife: Irss than 15 min 10-60 min IMisubcuufl!'OUs
Duration:
min 1V;30-120 min IMf!Ubcutan~us;3~ h topical
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LlbTl51s:
HflbaVFood: Unknown
Trrat mt nt of Overdose: OV!'rdos~ may
udlyr:ardia oInd h)'pffimsion.
Treatment with an alpha blo.:ker SIKh il plltntoi;!mifl!' (Regitifl!') fIIiIy ind~
(attd to dt<rus~ blood pres5Ure.
Ie
frIr
Ie rNs
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1 54
Unlll
lheNetv"",.Synem
NREM llagt2
NI'iEM~l
"REM stJgt4
~lting ~illo i
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eNS depression should be viewed as a continuum ranging from relaxation, to sedation, to the induction of sleep
and anesthesia. Coma and death are the end stages of eNS
depression. Some drug classes are capable of producing the
full range of eNS depression from calming to anesthesia,
whee","s others ~ee les. efficacious. Medic~tion. th~t depress
the eNS are sometimes called sfdati-m because of their abilityto sedate or relax a patient. At higher doses, some of these
drugs are called hypnotics because of their ability to induce
sleep. Thus, the term serlati~-hypnoti c is often used to describe a drug with the ability to produce a calming effect at
lower doses and the ability to induce sleep at higher doses.
Tranquilizer is an older term, sometimes used to describe a
drug that produces a calm or tranquil feeling.
Many eNS depressants can cause physical and psychologic dependence, as discussed in chapter 1200. The withdrawal syndrome for some eNS depressants can cause
life-threatening neurologic reactions, including fever, psychosis, and seizures. Other withdrawal symptoms include
increased heart rate and lowered blood pressure; loss of appetite; muscle cramps; impairment of memory, wncentration, and orientation; abnormal sounds in the ears and
blurred vision; and insomnia, agitation, an.'ciety, and panic.
Obvious withdrawal symptoms typically last 2 to 4 weeks.
Subtle ones can last months.
Antidepressants
Starting in the 19605, antideprmanlS were used mainly to treat
depression or depression that accompanied anxiety. Today,
antidepressants are used not only to treat major depression
(chapter 1(00 ), but also to treat anxiety conditions including general anxiety disorder, obsessive--compulsive disorder,
panic, social phobia, and post-traumatic stress disorder.
Given the effectiveness of antidepressants for these conditions, many believe that in the future, anxiolytics and antidepressants will no longer be treated as separate drug
classes.
IlIapttr I(
155
On"
Adverse Effects
PO; 75- 100 mglda~ may gOOlia11'1 iOO!a~ 10 150- 300 mgfday
(Ult Iowtr ~ in norhoIpitalilfd patimts)
dom",amine !Anilr.in~)
dcsipliminr (tIoIpf.1mil,
Prnoffine.OIhe-s)
uimipramine {StI"montilj
~5id!llion,dnirJfl~orrhimQ~(hyportmion,
"""""
trin)kypromine IPolmate)
/taro ilKkitt ammon admsIo tfIe(\~ .IIiIIIfIIiniu. ilKkitts loffious adYerll' effKls.
ftU'/Olil1lil~ (1Jriox1
puoxe~M
l!'.til)
!tf1ralinr (ldoft)
Adverse Effects
ATYPICAL ANTIDEPRESSANTS
miniLlpinr (Remeron)
tr.zodonr IDrlyrtll
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hyporemion,drymMll. dilZillflJ,f<lI!n<WfKt, ~
MlfIlitilg..wto6111]
156
ADVERSE EFFECTS
Srrious ~ions includr dizzinrs~ naum, ifllOmn;" IOmnoitrmr,ronlulion,
,nd seizure if laken in OY!'rdoI!'.
Contraindications: This drug should not br used in p,tienu who aft bruslfeeding or within 14 da~ of MAOI thr"py.
ADMINISTRATION ALERTS
This medicaticn 5hou1d not br started until 14 days ha~Npsrd ,fler dis(ontinuing ' "I MAOI d~.
Inmn of IftIOI or hepatic im poi""""l or in oIdtr adults, rtductd d...... ift
"""'"
INTERACTIONS
1Wg- 1)ug: MAOfs IhoIMI bIo iI'IOidfd U to ll'IOIonins~,rY~ Irf
mal9lants~ ~with "'-Wfs aUrI mr:in IwfmMMoisis,
tpthHmi',MId ....ooorricinsubilily.
bdlil/oplam wil 0.:.- pI.Mw 1eftI. or meloproIoI.od <inetidi ... "","'. ,...!
U\f or aIaIhoI MId oml'f(HS~B rnayfllh.wtO/Sdepr~nl!lfforu;
palifru shcUd.woid akohol whfn tJkiIg this drug.
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Cllaplfl t(
Benzodiazepines
The benzodiazepines are one of the most widely prescribed drug classes. The root word benZ() refers to an aromatic compound. Characteristic of an aromatic is its
carbon ring structure, which may be attached to another
carbon ring or to a dilferenl grouping 01 atoms. "jwo nitrogen atoms incorporated into the basic chemical structure
"n"
ANXIETYTHERAPY
cHordiaztpOlIid!, (librill!l)
1 57
Adverse Effects
~Itdolion,ltrhl7g)',oumQ
Mild in~I)':PO; ~-10 JOg tidar !jd;1M.IIV; SO- 1oo JOg 1 hbt(~a
mfdKal proadlI"~
SfoI~r~ anxiety: PO; 2O-1S JOg lid or qid; IMIIV; 50- 100 mg foIOW!'d
by2HOmgtidorqid
doniztpam (l<1000pinJ
dorazrpate (Tranxe~)
PO;HOmgbid
IMIIV; 2- 10 mg:rrprat ffnffiled in 3-. h
ioraupam (Ativin)
oxaupam (Strax)
INSOMNIA THERAPY
ffiazolam(Prosom)
~II1frlIr()/m(t, hfadocllt,mtmayimpomnr
ftlNazrpam (D.Jlmalll'j
AIJiDUIOM{tIj!
qlWl'pam (Doral)
~maz~pIIn
(Rl"lloriIJ
triarolim (Hikion}
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<pIN
158
Until Thl'Ne<voo,Sy'tem
Il'r Prototype Drug
Lorazepam (AtlVan)
Ther api! ut ic (lass: SedatiYt'-hypn otic; anxi olytic anesthet ic adju net
ADVERSE EFFECTS
ADMINISTRATION ALERTS
Wh~n administt ring IV, monitor rtspiratiom el'l'lY 5 to IS
airway and ~tative fquipm~nt acu-IIiblt.
Pl!goanq category D
PHARMACOKINETICS
1At5l!t: 1- 5min 1V;15-30min 1M
Peak: 2 h PO;90minlM
Half~ife: 111-20 h
Duration: Van;.blt
minut~'. H<l"I~
INTERACTIONS
l --
labTfltl: Untnown
pro<lK:~ IIfIbs SCKh ill 00, valerian, dlacmmilf,or hops ma, haole in ~itM>
efffCt with ml'dif.Jtion.Stimulant hairs sum oil CJOIU kola and rna huang may ffdlKe
ihl'drug~ elfectil'enesI.
TrNtm~nt
Rtftr IrI My/mIrrgKl for Q Mnbrg /'rOCef.l foon spt(1fc IrIIM /tug.
Barbiturates
Barbiturates are drugs derived from barbituric ~cid. They
are powerful eNS depressants prescribed for their sedative,
hypnotic. and antiseizure effects that have been used in
pharmacotherapy since the early 1900s.
as Sedatives
Until the discovery of the benzodiazepines, barbiturates
were the drugs of choice for treating anxiety and insomnia
(see Table 14.5).A1though barbiturates are still indicated for
several conditions, they are rarely, if ever, prescribed for
treating anxiety or insomnia because of significant adverse
effects and the avail~bility of more effective medications.
The risk of psychologic and phr-;ical dependence is highseveral are Schedule II drugs. The withdr~wal syndrome
from barbiturates is extremely severe and can befatal. Overdose results in profoWld respiratory depression, hypoten-
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sion, and shock. Barbiturates have been used to commit suicide, and death due to overdose is not uncommon.
Barbitur~tes are capable of depressing CNS function at all
levels. Like benzodiazepines, barbiturates act by binding to
GABA re.:eptor- chloride channel mole.:ules, intensifying
the effect of GABA throughout the brain. At low doses they
IlIapttr It
I S9
Adverse Effects
SHORT ACTING
Stdati~:PO;10 -10 mg
bid orqid
Hypnotic PO;I20-lOOmg;IM.I50-200mg
Stdati~:PO: 100-100 mgld.lyiI thrn
diYidN ~
amobarbital (Amytal)
bid orlid
IIddwI stdIlion
Stdati~:PO:4Omlj1id
mtphobarbital (MebaralJ
Stdati~:PO;11 - 100 mg
tid or qid
~~samoItno:r
Nonbenzodiazepine, Nonbarbiturate
CNS Depressants
These drugs reduce anxiety symptoms but are chemically
different from the other anxiolytic drug classes.
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Unlll TteNetvoo,Synem
160
Zolpldem (Ambren)
ADVERSE EFFECTS
Although it is a 1Il0b~nzodimpint.zolpidtm <1m in a limilar fashion to facilititf GABA-mediat~d eNS dtprrslion io tht limbic. thalamic,and hypothalamic:
~ions.1t prem.H stagnln and IV of sftpand halooly mioor~Is on REM
Sftp."Theonlyindicationforzolpidemisforshort-urminsomniaman<lgl'OII'ot
(7to l 0diys).
ADMINISTRATION ALERTS
P~oanqrnrgory8
PHARMACOKINETICS
On",t: 7 27 nin
~ak:
O.5--Bh
Half~ifto: 1.7- 2.5h
Duration: H h
TABLE 14.6
T.... tm ~nt of Ove rdo, ~: GfMI. liHd ."mptomatic: ~nd support;" OII'.1Wln
Orug
Adverse Effects
buspiront (Bl6pir)
SedatiYr:PO;200 mg bidortid
H)1IOOtic::PO; SOO mg- I gil brdti~
reOII'ItronjRomm)
H)1IOOtk:PO;3 mg al btddOll'
liI/fplon (Sonata)
Q lOIpidem (Ambito)
H)1IOOtic::PO;5- 10 mg it bedtimt
ANTISEIZURE MEDICATION
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Stmm
JqbD\9D!mdmml'
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161
Assessment
Anlitty
Disturbtd Sletp Pattern
Fatigue
lnrfff,uN~ Coping
ktjyity IntoltrdlK~ (~Iattd to loss of sltrp Of ddytimt *tpines)
D~l(ient KnowIedgt (drug thtrapy)
Risk for lnju!)', Risk for Falls (~lattd to adYmt ~ffKh of drug thtrapy)
studia).
Obmin N5tlin~ vital signs and Wl'ighlA~ the patitnt's risk for lills.
AslI'Ss tht patient's ability to It(~iYr and undtflund instllluion.llKlude thr
la mily and carf<jiYrfl as I"ftdtd.
Asst lSmtnt throughout il dministration:
AslI'Ss for dt~1fd thrrapeutK rfletn (! .g.,I1i1rmntl of implO'/tm~nt in
anl~ty,appetit~,ability to (.i ll)' out AOCs. and iftp patterns normal~).
Continue periodic: monitoring ofli!'r and rrnal funnion l1udie.
AslI'Ss vital signs and Wl'ight periodically or ijsymptoml warrant.
AllI'Ss for and promptly report ildvtrw tlfem: ~)[(esiYr dinine~
drowsi III'ss,light-htadtdnrss, (onfusion, agitatio n, palpitation ~ !aC:hlUidia,
diuines or light-htadtdne~ and mUlQlIos~1 Wl'aknes~
(conrlrwed)
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162
Unltl
TheNetvOll'Sy""'"
Implemtntation
Inte-rvtntloM and (Ra tio nales)
h 'lring tMr.ptutic tff~l:
CoMinut .ssmmtnts as d&ribed tarlit!" Iof thmptVtic tfft.:1!. (If tilt
drug is gjYen for .nxiety, tilt pabtnt repom dtm-nd .~, imprlM'd
sletpand rating h.biu,~ {Oping,.nd abilitylo (;IllY out ADls
IOithout anxitty.1f lilt drug is giwn for slttp, tht palitllt re,orts lilt .bility
10 fan and ~in .11~.nd impro~ diytimt wikeulnmJ
Minirnldn91dftlSt fffKb:
Continur to I!IOII ~or vital sigm. mmt.1 shM, and lOOIIfIIItian .nd bIIancr
ptriodic.J~ k paniculally CMious with oIcItr .duM wbo.m 011 inaN!I:d
risk for fillh.{1lnI9s uSfd for .mciety ilrId IIttp m.yausttruSsivt
druwsiness,tnd diuinm, inm'iling thf riskoffalb and ~.)
Ensurt patitnt j,Jftty, tspt<iill, in oIdtr -'uk!.. CltMM forlighthN~dnt!SOf diuintS~ Monitor Imbularion until tht tfft<ts of drug lit
known. {Dizzintss.nd dlOWlintss for a plDblged pmod oflilll!' rnayoour;
~Pf.1 011 tilt drug's h.f-ift. D.Jytimt drowsintSs mi)' impair WIIbIg
tht abrlity to carry OOJI USUil AOIJ.)
lslffi kIr diMlQts in Irvd of (OIlICiousnm,disoritnlilion or(onfusion,Of
~ion. {Ntutologic changes may indiuae O'itrrntdiutioft orfl'lt<u fA
IIttpdeprinrionJ
......
oltma.
Ostruct tilt patient to I.iR tht drug txaetIr ~ prI'ICribed .nd to not Slop ;;
.bruptly.
OstnKt tilt- patient th.lt thtst drugs should no! be krpl" tht btdsiOt to
..m:I liking adcIlio~1 dosts wlltn drowsy.
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.......
163
Th. potiom ,hould bubl. 1<1 ""I< tilt 11'1>01\ for th. drug;oppropn.l<
dose and IChfduling;what ,mrlt rffects to oIM~ for and when to
II'port; and the amici!)'t~d length of mtdKation therapy.
Th~
ihtr,py by confinning that !)'tirnt ~Isand np1l'd out{om~s hl'lf been m!'t (~Planning1 .
. Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If anyof these points are not clear, refer to the numbered section within the chapter for review.
14.1
14.2
14.)
14.4
14.7
When taken properly, antidepressants can reduce symptoms of panic and anxiety. First-line medications include the selective serotonin reuptake inhibitors (SSRls )
and other antidepressants; tricyclic antidepressants
(TCAs) and monoamine oxidase inhibitors (MAOIs)
are older drug groups.
14.1
Benzodiazepines are drugs of choice for the management of anxiety disorders and insonmia.
14.9
Because of their adverse effects and high potential for dependency, barbiturates are rarely used to treat insomnia..
Insomnia is a sleep disorder that may be caused by anxiety. Nonpharmacologic means should be attempted
prior to initiating pharmacotherapy.
14.5
14.6
CNS agents, including anxiolytics, sedatives, and hyp notics, are used to treat anxiety and insomnia..
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14.10 Some commonly prescribed agents and CNS depressants not related to the benzodiazepines or barbiturates
are used for the treatment of anxiety and sleeplessness.
16 4
Until
Thl'Ne<voo,Synem
A patient hasheengiwn instructionsaboUi the newly prescribed medication alprazolam (Xanax). Which of these
statements, if made by the' patient, would indicatt'that the
patient nreds furtht'r instruction!
my job."
3. "lUke this medication Ilmow that I needed it to treat
my anxiety, which is /lOW betlt'r, but I think it just makes
me feel good,so I am planning to stayon it for quite
awhilt'."
4. "I thought this medication vrould make me think
clrurly. but I don't ft'el. any chang<> in my feelings."
II
Education giwn to patit'nts about tht' use of benzodi aupines should include' an e'mphasis on what important
issue!
1. TheywiU be required lifelong toachit,'e lasting effects.
2. They requirt' frequent blood COWlts to amid adverse
.-
2. A 42-year-old female patient with ovarian canU'r sufft'red profound nausea and vomiting aftt'r her first round
of chemotht'rapy. The oncologist has added lom:repam
(Ativan ) 2 mg pe'r N piggyback with ondansetron
(Zofran) as part of th .. prech .. mother3py regimen. Con sult a drug handbook and discuss the purpost' for adding
this oonzodi"upine.
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EXPLORE
~.-----,
reliW rQls. I'lllll<ire for IiUGCIlSS with alfdilional NCL EX""s!j\e practice
Que5tloo5. Interactllie 9grvnent'l and actlliltles. web 11n<s. mtlMllDns
and videos. Inc! mille!
Rl!(JisW your aceess roM from 1M Iron! ot )'OUr 000Ic at
www.myn ..*.t kil c .....
DRUGS AT A GLANCE
LEARNING OUTCOMES
Benzodiaztpines
(K1IJt III
I4I diozepam (\otll/um) (K1IJt 174
(fJ9t III
Q p/lenytoln(D/bnlln) pilrJtllS
C V<'J .,role n,/d l""pnkPnp, r>PplJknr,.)
"",,,
NewerDrugs rwtllJ
SU((INIMIDES /it 174
Q elhowxlmk1e (Zoront...) (XJfJt 116
KEY TERMS
abstn(!seizurl' (XJfJt m
atonies/jzure paqt 168
convullions pogt 1M
rdampsia (IQIJt 167
epilepsy patll'166
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I.,
~1J(J
166
U"IIJ 1heNe<vooISyltem
SEIZURES
A wizIR or dinially dt'le(Ubie sign of tpilfpsy is a disturbance
of electrical activity in the brain that may affKt ConscioUliness,motor activity, andsens:ltion. Seizures are aused byabnormal or uncontrolled n~uronaJ discharges. Uncontrolled
charges may remain in one focus or prop3gate to other areas
of the brain. Ju. a valuable tool in measuring uncontrolled
neuronal activity, the ele(:tfoencephalograrn (EG) is useful
in diagnosing seizure disorders. ~ Figure IS.l compares normal and abnormal neuronal tracings.
The terms seizl.re and colIl'lO/sio., are not synonymous.
(onvulyons specifically refer to involuntary, violent spasms of
the large skeletal muscles of the face, nock, arms, and legs.Although some typeS of seizures involve convulsions, other
seizures do not Thus, it may bestated that all convulsions are
.seizures, but not all seizures are convulsions. Because of this
difference, drug'> described in this chapter willgeneraJ.ly be referred to as anristizure drugs rather than a"ricoru'loonN. Recognizing also that antiseiwre drug'> are commonly called
antWpil..pric drugs (AEDs), dle term anristizure in thi!; chapter applies to the treatment of all seizu re- rel~ted symptoms
indudingsigns of epilepsy.
~raIia<:I
~
tonic-dorOc MillIN
Figure 15. I EEG rl!<Ofdlngs showing tne dffferencfs IM!tween normal,absence setzurf',aod geooralt~ tonlc-dook: sqjaJf1! trKlngs
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''''''If.t5 Drug<forSelzult'1
An important topic when discussing epilepsy and seizure
treatntent is pregnancy. Because several antiseizure drugs
decrease the effectiveness of oral contraceptives, additional
barrier methods of birth control should be practiced to
avoid lUlintended pregnancy. Prior to pregnancy and considering the serious nature of seizures, patients should consult with their health care provider to determine the most
appropriate plan of action for seizure control. \Vhen patients become pregnant, extreme caution is necessary. Most
antiseizure drugs are pregnancy category D. Some antiseizure drugs may cause folate deficiency, a condition correlated with fetal neural tube defects. Vitamin supplements
may be necessary. Edlmpsia is a severe hypertensive disorder
of pregnancy, characterized by seizures, coma, and perinatal
mortality. Eclampsia is likely to occur from around the 20th
week of gestation until at least I week after delivery of the
baby. Roughly one fourth of patients with eclampsia e.""l:perience seizures within 72 hours postpartum.
Seizures can have a significant impact on the quality of
life. They may cause serious injury if they occur while a person is driving a vehicle or performing a dangerous activity.
Almost all states will not grant,orwill take away, a driver's licen... ami r"'l"ire a ,~il.llre_free period hefoTe gmnting th~
license. Without successful pharmacotherapy, epilepsy can
severely limit participation in school, employment, and social activities and can affect self-esteem. Chronic depression
may accompany poorly controlled seizures. Important considerations in nursing care include identifying patients at
risk for seizures, docwnenting the pallern and type of
seizure activity, and implementing safety precautions. In
collaboration with the patient, the health care provider,
pharmacist, and nurse are instnunental in achieving positive
therapeutic outoomes. Through a combination of pharmacotherapy, patient- family support, and education, effective
seizure control can b~ achieved in a majority of patients.
L tFESPAN CO NStDERATtON S
..,"'.
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167
and difficulty speaking are other behaviors a person may exhibit during a seizure. Determining the cause of recurrent
seizures is important for planning appropriate drug selection and treatment options. Proper diagnosis therefore, is
essential.
M('!hods of classifying epilepsy have changed over time.
For example, the terms grand mal and petit mal epilepsy
have, for the most part, been replaced by more descriptive
and detailed categorization. Epilepsies are typically identified using the International Classification of Epileptic
Seizllres nomenclature, as partial (focal), generalizl, and
special epileptic syndromes (see Table 15.1). Types of partial
(fOCllll or generalized sti lU~s may be recognized based onsymptoms observed during a seizure episode. Some symptoms
are subtle and reflect the specific nature of neuronal misfiring; others are more comple."I:.
"
"""
Simp~panial
Symptoms
-'
Ilfactory.iuditory.i'Khiswl halkKinations
Inl\'n~
mlO!ions
lwiKhingofi'm~ltg~andoo
Awol (preading)
Britf ptriod of (onfusion or ~ss afit!Wiro with no mrnlOll of s.rizLno Iposri!/QI roofug'm)
flJnblingw~h Of aUtmplilg to ~ dolhing
No IfIIIOn~ to 'lffilil (ommandl
0;;;.,
~(pr!~min
Cl)ing at IJr9n"ngmi, Iral'fllungs; loss ofbowtl~ (ont,oI; shallow oo-atling with ptriods 01
ipMa;U5Uiliy lining 1- 1miMe
Disorientation ind dtfp ~~ ifitl sftllll' 1posrk1~lut)
SptWlsyndrome
Ftbrilt lfilll'r
Myodonic: srizu,r
SUlUSrpiltptiws
Consideredamrdic:il~nq
Comiooouslfil!ll' actil'il:~ whidJ un ~id to(OIIIi and~atli
with Iheir health care provider. The sum of this review indicated that although the older antiseizure drugs have serious clinical drawbacks, so do the newer antiseizure
drugs.
Many of the newer antiseizure medications are used in
adjlUlctive therapy. Some drugs are being evaluated for their
potential use in monotherapy. In most cases, effective
seizure management can be obtained using only a single
drug. For some patients, two antiseizure medications may
be needed, although unwanted side effects may appear.
Some antiseizure drug combinations may actually increase
the incidence of seizures. The nurse should consult with
current drug guides regarding drug use in monotherapy and
compatibility before a second antiseizure drug is added to
the regimen.
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PHARMFACTS
Epilepsy
Thf word tpilrpsy is ~rived f,om the Gfl'rk word tpiIqnKJ, muning"to
IiIkr hold of Of to~.
About2millionAmerKanlhaw~pilepsy.
One of f'YI'ry 100 trrnag~rs h.il rpilrpsy.
Of the U.S. populnion, 10% will hoiVI' seizurH within thrir Iiletillll'.
Most PfOplewith seizurH an')OOngtI' than 4S ~rars of alit.
Contrary 10 populu btlitt il is impossiblt to 1W!llow the tongue during a
ltU:uR.and ont mould n~' lorn' an objf(1 into the mouth of someone
who is having a ~il:Ufl'.
Epiltpsy is nOlI menlill iIInt55; mildfl'n with rpilepl~ h.ivr 10 I<Om
equivalent to tho~ oI(hild~n wilhout the disordtr.
~amolll prople who had rpilepsy inc:ludt .kJlius (1~1i~ Almnder the
GrN~ Napolron, Vinc:~t van Gogh,Cha~ OKktn~JNn of An, matn,
Aqatha Christit, Truman Capote,and Richa,d Bunon.
Among iduk akoholics l1'(~ving IrNtment fo, withdrawa~over haN will
l'iIIperierK:~ still"e within 6 hours upon aniving for ut'.Hmtni.
("'Plfr 15
gabapmtin (Nell'onIin)
~m(Ati\\ln)
phtnobarbital(lumilal )
pregabali'l (l,nu)
primidont(MySOiM)
tiagabi!H' (Gabitri)
lOpiramate (lopamax)
HYDANTOIN AND NEWEll DIlUGS
urbam.J!!pint (ltgrtlol)
Iall'lOU'i9nt(limimn
Inetir.Kelam (Krppri)
ouarburpi!H' (lri ~pllll)
pht~oin
(Ililantil)
nlproi(~ ( Dtpak_)
lOOisamide (ZOntgran)
,
,
,
,
,
,
,
,
,
,
,
,
,
SUCCINIMIDES
t\h&IUximide (ZaroJltinj
Abwnce
Tonlc-Clonlc
Myoclonic
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169
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
ing. Anydrug that blocks glutamate activity prevents an influx of positive ions into the ceU, so this is consistent with
the last two mechanisms.
170
Unltl TheNe<vomSy'tem
PHARMACOTHERAPY ILLUSTRATED
15.1 Model of the GABA Receptor- Chloride Channel Molecules in Relationship
to Antiseizure Pharmacotherapy
Seizure Ktivity: E pHp'-'
Barbituralea
Hydantoins and """"' ... "!1"nts
SuccinrnidM
Anlagonism 01 Glutamate
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171
Adverse Effects
BARBITURATES
amobarbitallAmytin
1V;6HOOmg(mil:1 g)
mtphob.Jrbitall Mtbiral)
PO:400-600 mglday
Ag@DuloMO\jiSuwrn_Ig/DlQIlwD!tpme ,JOOioo!erN
p/IffiobarbiIaHwmina')
20 rng~
BENZODIAZEPINES
doniztpam (KIooopinJ
dorUl'paltlTraro:~lIt)
diazl'pam (Valium)
gabilpmtin (Nl'\IIOnlinJ
pll'gabillil (l)Tica)
liagabilH' [GabitriJ
lOpiramatt (Topamax)
Barbiturates
Barbiturates are organic compounds derived from barbituric acid. All derivatives intensify the effect of GABA in the
brain and generally depress the firing of CNS neurons.
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,a
2
"~
172
Unlll TheNe<v"",.Sy.tem
I PhenobarbItal (Luminal)
ADVERSE EFFECTS
is a long-acting barbirurate usrd for tilt management of a variel)' of seizurrs. k is also und to promote lI~ep. Phen obarbitalshould not ~ wd
for pain ....1;.(", it ma, i!l<rNIU pot~t'< ~n<itivity to poin.
Phtnobarbitt Iam biochtmicaliy by tnhallCing the xtion of tht GABA neurotransmitter, which is rrsponsible for suppressing abOO/mal neuronal discharges that can caUll' ~Iepsy.
Plltnobarbital is. Schedule IV drug thit m" talU drptndencd ommon side
rifls indudt drowsinffi, vitamin drr"iffiOts (vitamin D; folat~ Of II,; and
Bu). nd laryngo<pa<m<.With ownIo.... phmoborbiul m. , cause .. ~'" ""Pi_
I1tory depreSlion, (NS deprtlSion, coma, ~nd death.
Contraindications: Mminimation of phtnobarbit,1 is inadvil:able in m e of
hypernn~tivil)' to b,rbiturates, ~ uncontrolled pain, prHxisiting (NS deprrslion, porphyri.t~!t"\'!'''' ~piratol)' disease with dyspnta or obstruction,
and glaucoma or prostatic hypertrophy.
Ph~nob.Jrbital
ADMINISTRATION ALERTS
INTERACTIONS
I)ug- l)ug: PIKonobarIitaI inreraru with mony otIPr ~ for !LJmplf. ~!ohoo.jd
no! II! 1M with akohol If other (1fS dioprflSann. The!t substance! pottrtiate
barbiunte action,ino&l\iIg til! rill: of ift-thr&llHlilg ~OI)' dep"fISion or
ooIiac arr& PhPnobarbitai iOONlfS til! rnetilbotilm of manyother d~ r!'diKing
their~1.
PHARMACOKINETICS
(),sel: 20-60 min PO; Smin IV
......,.
Half~ife:2....sd.~
Trtatment of INtrdole: Thert is no spuific trutmtnl for owrdost. Drug rtmo\\ll may ~ momplished b, g'lIric IaIll9t or U\e of .!aivated diartoaL He-
Duration:6- 10 h PD;4- 10 h IV
Benzodiazepines
Like barbiturates, b,mzodiazepines intensify the effect of
GABA in the brain. The benzodiazepines bind directlytothe
GABA receptor, suppressing abnormal neuronal foci.
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("",10,15
Drug<fo,Selzu,e.
173
""9
Adve~
PO; lS- 18 mgillg or l-g inilial dosr;lhtn 300 mglday ill - 3 dividtd
dosrt; may bf gOOuil1y iOONsrd 100 f1l9,I'wffk
Agranu!ocytMaplilli!: allmlias;bu!!M,ufolialivto!
Effects
HYDANTOINS
fosphtnytoin (u"dIyx)
Q trJ)'Ioin (Dilanlin)
9i/l9ival
~fMrpklfill
PHENYTOINL1KE DRUGS
45 mWt9lday
PO;SO ~day for 2 wk, 1IIffi SO IIIIj bid for 2wk; may ilKrusr 9radlil1y
!4l10 lOO-SOO m~day in 2 dividtd dosr! (mal;700 mglday)
lMIi,aulam (Krppfa)
orurIIazrpiM (Triirplal)
Q '/a~add
(Drpak_,Drpakol~)"
~~~boM
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~
i
i
I Diazepam (Valium)
ADVERSE EFFECTS
D~zt~m
ADMINISTRATION ALERTS
Whtn .dministering 1'1; lIIOIIitor Jt5jIiIatiom Mry 5 10 15 min<.m. HiM
airway ilIId JtIIII(itltM!@IIuipmtNI((HSibit.
PrtgIIilIIC)' Ulf'IJOf)" 0
PHARMACOKINETICS
(Mset: 10-60 mill PO; 15-30 min IV
PNII:: l-lhl'l);Hmin1M;1-5mi11 IV
Halflilr: lo-SO h
Dmtion: 2-1hl'l); lHiO min IV
TABLE 15.S
Succinimides
we.
176
Unlll TteNetvoo,Synem
"
ADVERSE EFFECTS
Side ellras iKkm !fdation,drowsms,GI upstI.and prolonged bletding bill!'.
Other NItm iKkm v~1 dilrulbalKn,lIIUidt WNkne~ tll'mtr; Pl){homotor
igitltion, boot nYmlW IUpprmion, 'Might gain, abOJmilal oa mp!, rash, alopr0" pruritu~ photo5t05itivity, t~ mukifOllO!', and fatal ~OIo:Go:ity.
Contraindication!: Hypmeositivity may oc:rur. Th~ medication Ihould not be
admin~ttrtd to patitml with I~r di!ult, bletding dysfunctiol, palKlI'ilit~,
ind (ongtnital mmbolic di<ordtn..
INTERACTIONS
l)ug-l)ug: YaiproiI: arid inlerarts wiIIl many dlll9l. f 1'IiIm~,aIJi in,
00IWdine, <Norprornaz_, fI)'/hrorny<in, and ffIIamate may i"KruIio 1l!Ipr<t add
tmid/)'. Coocomirant wil'farin, alpi'in, or akd"d l1li' ran (iJU\f It'Il'II' 1H;>diDg.
AIutIoI, beozOliaz~ and othtr OIS IIfpm.sam pciPlltialf CHS dnr@l~t
iKIicn lIIf of dooazfpam (OIKUIl!fltly with uproil:add may ilduaiNoo
If'illl@l.lIaIproiI: add ino~loKum ~I and p/lfoyroil ~~
larnoiri9irw. ~toin,and ri~n IowflVaiproil: add ~
Lab 11'115: Unknown
Ili!rbaVFoo:1: Unknown
PHARMACOKINETICS
()Jstt: RNdi~' ab!orbed from th~ GI tract
Peak: 1--4h
Half~ife: S- lJ h
TlNtment of Owordose: Theil' i< no Ipe(ifK tll'anneot for OftdOle. Drug 11'mo\\ll may lit ac(omplishtd by gastric: li~, usr of activated dwrroal, or la~
ilin. TlI'almtm ~ IUppon~ and (onsim mainly of maiOtlinlig tht airway
ind bll'ilhiog. monitoring plltrr;toin Ievek,ind appropriately tl1'ating adl'l'llt
l)'IlIptolnS.
Duration: Variablt
I EthOSUXimide (Zarontm)
Ethowu midt i< adrug of (hoic~ for ableoc:~ (petit maO Itizull'!. k depll'SIt! the
activity of IltUI'OIlS in tilt motor mnn by elmting tilt IltUlOIIil thrr4lold.1t is
uwal~ intffNtil!' igainn ps)'(homotor or tonic-donic Itizurrs; ~r, it
may lit ginn in mmbinarion with othtr mtdicarioM thit littler treat tlltlt
{onditions. k ~ "'ililablt in ubiet and flawlI'd-syrup formulation!.
ADMINISTRATION ALERTS
Do not abruptly withdraw !hi< mtdilabon bt<ausr doing 10 may indKr
tonic-tlonic v.izulI's.
PlI'9oancy cattgory (
ADVERSE EFFECTS
Etho!urimidt nYyimpairmentaland physicalabilitits.~ho!isormrerTll' mood
swirqs, inWding depl!'!Sion with a'rt ",icidal intent, un 0ffiI". Behavioral
dw~ ill' more promilent in Ilalitnts with I history of psyrhi.mc: ilM!. (mtral OI'I'IOIIS S)'SItm efferu indJde diuine~ he.Klac:ht, lethargy, fat~.nalia,
Iftppattemdisturbaras,atttnliondiflkuity,andhimJpI.Bontmarrowsupprts<ion.nd blood dyKruia, ... p05Siblo, ... ;' <y<1rmic: "'I'I"~
Otlltr lI'actions ilKlude gingiva Ih)'pertroph)' and tongut sWflling. Common
Iide ~fferu all' abdominal di<I~!and Wfight los!.
Contraindications: HY~lIensitivity may (KW'. Do oot ulr this medication in
mrs of !rftre lin, or kidney diINlt. Safety in (hildll'n YOUOgtl!hi n3 ~an of
agt !ws not ~n tstablishtd.
...
INTERACTIONS
PHARMACOKINETICS
()Jstt: Rtadi~' ab!orbed from thr GI tract
Peak: 4 h
Half~ife: 30 hin (hildll'O;60 h in adull!
Duration: Variablt
TlNlment of OwordOS!: Th~re i< no Ipe(ifK trurmmt for OftdOlr. Drug 11'mo\\ll nYy indoor rmesi< unltss the patitnt i< (omato~ or mll'Jl~ng. TlI'arIO!'nt may be mompii!hed by gillric: Imgt, usr of activattd (haKoal or
m!wniu,ind geo~ral supponiW' mu",rrs. Htmodialysi< may be eIflMo in
fariliutingll'lIIO\\Il of t rhosuximide from tht bod)'.
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("'Plfr 15
177
Assessment
Tnch th. j)ititnt to riIt from lying or lilting to nanding slowly to mid
dill.inen or falk.
l~tllJ(t th~ patirM to call for u~tan~ prior to gening oot ofbtd or
attempting to walkaloll!', and to aYoid driYing or atlltr oJ(tivit~ 1tqUiring
mtftLlI altnness or physical coordination until th~ tffNIs of th. drug a",
k_.
(conrlrruefi)
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LibraryPirate
)nmuu thr p.llient on thr IIC'rdto return periodkaUy for lab wort.
IlIIIruct t~ poatitnt to UIIY a walltt identification utd or Wl'ar medical
idmifution it'M'11' ildiming a smtJredilorder and antisMR medKation.
T_ h thf patitnt to promptly rt port any abdomini llHlin,poanKuiarly in t~
upptr quadrants;(ha~ in slool (oIor;)'fllowing of sdera or skin;or
dlluoed urinr.
InstnKt t~ patien~ family, or cart9m r to immediatrly II'port inc:lI'iIsing
!fthargy, disorientation, {OfIfiKio n, (hangl's in brhavior or mood, durre:l
Ipffih,or mxil.
InstnKt t~ patienl to immediately report any visual (hange or ~e pain.
InstnKt t~ patient to ta~ the drug eX.Ktly u presc:ribed and to not stop it
abruptly.
InstnKt t~ patient that ~ drugs should not bt ktpt at the bedside and
toavoid taking additiona)!lasn whrn drowsy.
Tt.Kh tht patitn~ family,or w egiver about support groups and ma~
appropriate II'ffrrals II nmled.
179
The patitm should R a~ to Stitt the ~a!On for tht drug; appropriate doW'
and lCheduling; willi! <I~rW' eflect:> toollW'rYf for <l nd when to rrpon; <l nd
tht imicipatt<l length of mrdicition therapy.
IH,QOO IUfor 1M ridflllllfl1fr"hj(h mtst rmirIgljcm~pIy. i"Stt~lJotllt IWingf'rol.mFOMUli* milr<flm 14ilfrmDlDlreIomilfl ~tnd
No~~ltr!gsCIO
. Chapter REVIEW
KEY CONCEPTS
The numbered kt-y concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not clear, refer to the numbered section within the chapter for review.
15.1 Seizures are symptomatic of an underlying disorder and
are associatoo with many causes, including head trauma,
brain infection, fluid and electrolyte imbalance, hypoxia,
stroke, brain tumors, and high fever in children. Pregnancy and quality of life are importam issues to consider
when discussing epilepsy and seizure management.
15.2 The three broad ,ategori.-s of seizUI.-s are partial
seizures, generalized seizures, and special epileptic syndromes. Each seizure type has a characteristic set of
signs. Comrol of seizures requires proper diagnosis and
drug selection.
15.1 Both traditional and newer antiseizure drugs are indicatoo for seizures. Both drug classes have serious draw-
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180
Until TheNelv"",.Sy.tem
15.6 Hydantoin and related drugs act by delaying sodium in flux into neurons. Phenytoin, carbamazepine, and oxcarbazepine are broad -spectrum drugs used for aU types of
epilepsy except absence seizures. Valproic acid and lam -
The nurse re;:ognizes that several chemicals inhibit neurotransmiller function in the brain. The primary inhibitory
transmiller in the brain is:
1. sodium.
2. GABA.
3. chloride.
4. calcium.
levels.
2. expecting a discoloration of oontact lenses.
3. immediately reponing unusual bleed.ingor bruises t o
the health care provider.
4. expecting a green discoloration of urine.
II
2. A 24-year-old woman is brought to the emergency depart ment by her husband. He tells the triage nurse that hiswife
has bern treated for seizure disorder secondary to a head
injury she received in an automobile accident. She takes
phenytoin {Dilantin} 100 mg every 8 hours. He relates a
history of increasing drowsiness and lethargy in his wife
owrthe past 24 hours. A phenytoin level is performed, and
the nurse notes that the results are 24 mcgldL. Relate the
drug regimen to this patient's presentation.
3. The nurse is admitting a 17-year-old female patient with a
history of seizure disorder. The patient has broken her leg
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EXPLORE
M)'MlrSi1g~
~~------,
is yoor one stop fa" ooIifW! !:napier reVIew miltel1alS aod
DRUGS AT A GLANCE
LEARNING OUTCOMES
After reading mis chapler, the student should be able to:
ANTIDEPRESSANTS JIalII8J
TricydicAntidepressants (TCAs)
(JY/t
184
pagtl88
MAO Inhibitors(MAOls)
pllJl l89
Q phenelllne (Nardll)
f'jt If()
fII1'J'191
Q /lrhlum {Eskalllh} {IQIJt 194
Antiseizure Drugs
{IQIJt
193
{IQIJt
Ill!
{lQlJt200
KEY TERMS
attention deficit-hyper.ctivity di~rder (ADHD)
Ill"" 191
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mania patjtl'lJ
monoaminfoxidase inhibitor (MAOI) pagt189
mood disorder {!all 181
moodstabilim (!alI19J
postpartum depresion paqt 181
psychotic depression pagt 181
seasonal affective disorder (SAD) pi!9f 181
,.,,"
182
UnllJ TheNe"""ISSystem
feeling well or functioning normally. Because depressed patients may be found in multiple settings, every nurSE' should
be proficient in the assl$S ment of patients affiicted wilh this
condition.
Some women experiellCe intense mood shifts associa ted
with hormoNI changes d uri ng the m ens trual cycle, pregnancy, childbirth, and m enopause. Up to 80% o(women experience pMtparl\n dtpmsion during the first seve ral weeks
after birth of their baby. About 10% of new mothers experience a major deprl$Sive episode within 6 months related to
the dnmatic hormona l shith th:lt occur during pouddivery.
Along wi th the hormonal ch:l nges, additiona l situationa l
stresses su ch as responsibi litieli at home or work. single par_
enthood, and caring for children o r for aging p;).fents, may
contribute to tbeonset of sym pto ms. If mood is severely depressed and persists long enough, many women wiUlikely
benefit from medical treatment, including those with premenstrua] dysphoric di sorder, depression during pregnancy,
postpartum mood disorders, or menopausal distress.
Because of the possible consequences of perinDlal mood
disorders, some state agencies mandate that all new mothers
after giving birth receive informatio n aboul mood shifts
prior to th eir discharge. Health care providers in obstetri cian's offices, pediatric outpatient settings,and family med_
icine centers are encou raged to condu(l rouline screening
for symptoms of perinatal mood disorders.
During the dark winter months, some patients experience
INsonaI.tfedm disordtrlSADI. This type of depress ion is associated with enhanced release of the brain neurohormone
melatonin due to lower Light levels. Exposing patients on a
regular basis to specific light therapy may relieve SAD de_
pression and prevent future episodes.
DEPRESSION
DrpmWn is ~ d isorder dUr.lcterized by 11 ~d o r desponden t
mood. Many symptoms art associ3tW with deprl$Sion, including lack of energy, sleep disturbances, abnonnal eating
patterns, and flings of despair, guilt, or hopelessness. De pression is the most common mental health disorder of elderlyadults , encompassing a variety of physical, emotional,
cognitive, and soci al considerations.
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o..plfll6
Psychotic: deprrssion is char,Jcterized by the expression of intense mood shifts and unusual beh~viors. Depressive signs
and loss of oont~ct with re.tiity, haJludn~tions, delusiom,
and disorganized spee<:h patterns are the behaviors observed. For psychotic patien ts and for patients with extreme
mood swings, severe behaviors are often treatable wi th antips~hOl ic ther,Jpy. ~ se<:tion ]6.8 of this chapter and
dlap ter 1700.
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Drug' for
EmoUon~t ~nd
Mood Disooden
183
maj or depressive disorder (O'Reardon, 2007). Thil trutment requires surgical implant of the device. In contrast to
ECf, rTMS produces minimal effts on memol)', do-es not
require gener.ti anesthesia, and is helpful without the overt
risk of generalized seizures.
Ewn with m e best pmfession.ti care, the patient wi th depr=ion may take a long time to recover. Many individ uals
with major depression have mu ltiple bouts of the il lnESS over
thecouTS('of a lifetime. This can t:l.ke its toll on the patien!"s
family, friends, and olher caregivers who may sometimes feel
burned o ut , frustrated, or even depressed themselves. They
m ay experience episodes of anger towa rd the depressed
loved one, only to subsequendy suffer reactions of guilt over
bein8 angl)'. Although such feelings are common, they ClIO
be distress ing, and the caregiver may not know where to t um
for help. It is often the nurse who is best ~ble to assist the
family members of a person suffering from depression. Family members may need counseling themselves.
ANTIDEPRESSANTS
Drugs used to treat depression are ca tegorized as antid epressants. Antidepress.ants trea t depression by enh.anci ng mood.
Over the years, mood has rome to represent a broader term ,
encompassing feelings of phobia, obsessive-compu lsive behavior, panic, and anxiety. Thus, an tidepr~nu are often
prescribed for these disorders as well. Rent studies link depression and anxiety to similar neurotransmitter dysfunction , and both .\.eem 10 respond to treatment with
antidepr~nt medications (chapter] 40'=1 ) Antidepressants
are also benefici.ti in treating psydloJogic and physical signs
of pain (dl apter I sex , especi.tily in patients without major
depressive disorder, lOr example, ",nen mood problems are
assoc:iated with debilitating a)ndilions such as tibromylagia
or InlSCle spastici[}" (chapter 2100).
There is one importan t warning ~bout antidepresSints; In
2004, the U.S. Food and DrugAdm inistration issued an advisory~black box warning" to be included at the beginni ng
of drug package inserts and d rug in format ion sheE1s. The
advisory was iss ued to patien ts, fam ilies, and heahh professionals to closely monilor adults and children taking l nt idepres..<ants for warning signs of suicide, espe<:ially at the
beginning of treatment and when doses are ch~nged. The
PHARMFACTS
UUlmrnt.
unl\awrlr IOill)'Ollr.
"
184
Until The
/IIe<v",,, Sy'tem
Depression is associated with dysfunction of neurotransmitters in regioru; of the brain connected with focused cognition and emotion. Although medication does not
completely restore chemical imbalances, it may help reduce
depressive symptoms while the patient develops effective
means of coping.
~ shown in Pharmacology Illustrated 16.1, antidepressants are theorized to exert effects through actioru; on specific
neurotransmitters in the brain, including norepinephrine,
serotonin, and dopamine. The two basic mechanisms of drug
action are slowing the reuptake of serotonin and norepinephrine and blocking the enzymatic breakdown of norepinephrine. Within centrally located synaptic terminals,
monoamine oxidase (MAO) enzymes normally break
down catecholamines and recycle them for further use
(chapter 1300 ). Making catecholamines more available
by either inhibiting MAO elllymes or inhibiting neurotransmitter uptake, enhances activation of adrenergic receptors. The primary classes of antidepressant drugs, listed
in Table 16.1, are as follows:
Tricyclic antidepressants (TCAs)
Selective serotonin reuptake inhibitors (SSRIs)
Atypical antidepressants including the
serotonin- norepinephine reuptake inhibitors (SNRls)
Monoamine oxidase inhibitors (MAOls)
Trlcy(li( Antidepressants
Named for their three-ring chemical structure, tricy<~(antidf
(TCAs) were the mainstay of depression pharma cotherapy from the early 1960s lUltil the 19805, and are still
used today.
p~ssants
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However, TCAscontinued to have some unpleasant and serious side effects. The most common side effect is orthostatic
hypotension, due to alpha, blockade on blood vessels. The
most serious adverse effect occurs when TCAs accrunulate in
cardiac tissue. Although rare, cardiac dysrhythmias can occur.
Sedation is a frequently reported complaint at the initiation of therapy, though patients may become tolerant to this
effect after several weeks of treatment. Most drugs have a
long half-life, which increases the risk of side effects, especially for patients with del~d excretion. Anticholinergic effects, such as dry mouth, coru;tipation, urinary retention,
e.lcessive perspiration, blurred vision, and tachycardia, are
common. These effects are less severe if the drug is gradu"
ally increased to the therapeutic dose over 2 to 3 weeks. Significant drug interactions can occur with CNS depressants,
sympathomimetks, anticholinergics, and MAO inhibitors .
Since the advent of newer antidepressants with fewer side
effects, TCAs are less frequently used as first-line drugs in
the treatment of depression andlor anxiety.
A2J..yw-old man WI! ~dmitttd Ihis moming following a suicidt Jttt mpt
when his girlfriend broke up with him. Wht n tilt nurse enl~S his room with
his medications, h~ is ulking on tilt ttltphont with his girlfriend. Ht ma~
t yecoMaa with Jnd motions for iIII' IlUrst 10 lu l'l' his IIIfIIk.uions on tilt
tablt 10 lit (an take th~m bttr.Tht nurst,oot wantinglO inltrrupt his(onl'l'rs.ltion, pun tht mtdiutionsontMublt,ltavrs iIII' room,anddlam tlltmedkations. Wh.u ~rror did th~ nUBf (ommit and what is tilt appropri.J1e nu r~ng
intmentionl
PHARMACOTHERAPY ILLUSTRATED
16.1 Antidepressant Therapy Is Directed Toward the Amelioration
of Depressive Symptoms
o
e
____
HfOton,n (S-HT)
Tncydic anlid&pnossantll
",1'WbiI r.. uptake of
NE and !rH T intc the
P!5Y""I'tOc: terminal; .....
:.
PcetsynapIIC
_ . ""
NE or 5-HT
No.maIy.
5 HT if; .....sed.
5HTbinds to its
po6b~lic rec.pt0l'
o 5HT
o
o "..
binds to its
p'"Y"l'P4ic reoeptor.
'.' .V
' .
I.
rotonin uptake
ill bIocksd, ITION &-HT
wi' be available in
!he synapIic apace.
SSRI, bIodIlhe
reuptaka of ..otcrin
into preaynaptic .......
t.-min8le. Incfeaeed
Ie....,. 01 aerotonin
neuro!mrwnitl. . inlo
Pf'M)"I4ptic nerve tmI!\Qt..
The affected
neurot ...nemitt. . I n
norepinephrine lind MfOlonin..
SNR!. ha .... a llirrilar
mechanilm. Their dMmicel
IIructI.Iu ... d iffen!l'1l from
indut;:e ~OmPID.
cNro!tM in prw)'Mplic
and ~ynaplic:
"'04
and pomynaplic
"""'P1ors become ""'"'
....a;.....
Tyroeine
'-do<>'
~nephri ....
('~
), .
"","\0
0"-...'"
/fi'
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_I"'"'.......
em,-
enzyme IICIMty.
, 101 opio' epho io..
lhett ......... ta
Ihoo action of
rooreplnephrine
and oIIwr
neurotranamitt......
degraded . MAOI. have an
ell.,;! of ..,t.nc:.d
catecholamine reIe&ae.
o
e
e
NE ;. ... leased.
NE binds wiIh
ilS.-"tOf.
The..:lion of NE
ia tenninal&d by
MAO and COMT.
O-melhyllrwwleraae
II MAO I'lnhibited, NE
ia net btokon down as
TABLE 16 1 Antidepressants
0""
~mill1XYlil~ (Elm)
.\dYerSt Effects
~m(I(,Jpinr !All'ndil)
OJI""
AIkIIl: PO;br9n wittJ 100 mg/dIf (IIYY ncrull'lII day 110 lOO 1ll9lda)');
GtMric PO: 2S mg It btd:imt:1U)' ino:tNlI' ~ )-7 dqs IG SG-150
"
domipr~ (Arlatrri)
<Ie!Ipmrine (Horpramift)
doIfIIn ISinrquan)
R\ilprvlih (llKimIi)
prolllplJline ('/M(III
trinipminr.' (Surmonli)
cilaiopmll (C!lw)
Q nduIopilm ~e
lkroRtint(Pro!ac)
~(l1Ma)
p.lttMeIine (PiXi)
Q !MfiI~(l*ft)
"i
..
~(WeUbutrln;lybM)
M!
~dry~in~KIIIIIOkn((fINdachr,
_l~ ~ GI rlistrJfNllln,tlniMSl, I/IIOrrxi~,
-~ <rre1!Jl!1lt
5fm:!J!-!qhmm
m~ (RmIftOI'I)
5trlTO)-lghpm 5'!!l!!mmr
trarocli:lnt (Deyrfl)
PO;25-125mgtid
bind;
lI'actions)
...>
_Olin f1'I4l!mt
:!Qt!!I.2!l!!!l:!I.~ IllIlr!2! m!i!!!! aL:!!~~ hUll
>
J ,"-,
-mol'"
iIoOOcIwid (Ma-pIin)
Q
Jilmdzine (Mardil)
tranplcrprooline (Pamatr)
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Omtni~ il!Grril,orrllU!larkhypor~bbrtd
BtUtiWllad
""""
1ri~II:milr: U~il
Wll1iI1Qll
1lI>p1tl16
187
I Imipramine (Toframl)
Plf9nanqcategoryC
PHARMACOKINETICS
Onsrt: ~,than 1h
Peak: 1- 2 hPO;30min 1M
Halflife:8-16h
~on: Variilble
ADVERSE EFFECTS
Side efftm incUdl' sedation, dlOW! illl'Ss, bkJITl'd filion, dry mouth, J nd cardiamrular symptoms sum '" dysrhythmia~ lINn blod, and 9tlfllle hyprrtellsion. ~nts that mimie the action of norepinephrilll' or serotonin should be
aYOidtel ~CilU imipramint inhibits tMir metabolism and may ~ tOllie
it)'. Some patients rna, elptril'nce photosensilivity Jnd hypersensitivity to tn.
cydicdrugs.
(ontraindi (.ltions: This drug should not be used in (.I~ of iKU1l' recovery af
1l'r Ml dtf1S in bundle-branch conduction, narrow~ngle glaucoma, and ~
Wit ft'nJI or hepatic impairment Pnitnn should not !lSI' this drug within 14
days of dilrominuing MAC4~
INTERACTIONS
DrurDrug: (IIIumnt U!f of othfr 0fS d@p"flWllu, ildlllingakDhot,IIW1(jlllf
lfIia!ioo. (inftitiM (Tigamftl may inhlJit !be IMlabohm of imiprarnilll', 0Ii1g
to ilamfd5flUmiNl'k alld possilH< toxidt~lmipr.llniN mayrM'Bf!lM>
.:lm,~weflKnof dooidillfalld potmtiat~O!S~sion.U\i> of oral
COOllOKfPtil'fl may mu or ~illipramillflmls.~ram ma,OI to
dttiliumand (j(ilyQrdia.~ "gam IIIiI1 p-oduu> ~nuloqlosis.
Pheno!hialine; c~ ilamfd iIIlkhotifm9ic: and SfdaIiw HlKl>.
SympillllomiMOO; may rrur: n a diac lOlidty. Ml1h~phMidm or dmetidilll' may
~!hI> HlKnofillipramMld CiUII' toxidty.f'hfnytoi1 is IN fflKIMwhi>n
!.1loPn wim imipramiw JMOk may Il!'iuk in OOIro1fptic maI~t \)'IlItorIII'.
Li bIfSlS: ImipramillfprocUcfl~ IMIodgu:O'if tr%. ENion ofserum
~irmiland atlritliol' pho:I~1lII' ~ li ~.
Helba VFood: H5ba1suppk>mmn SIKh iI ~ pri nrOlf oil or gi1k1jO. may101m
!1M> '>fizu"! mlWdd. >t. John \ wort USfd (OIKII"rmtl)' may (jU5f Sfrotonn
.,....,..
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188
Atypical Antidepressants
In terms of classification, the atypical antidepressants do
not fit conveniently into the other antidep ressant drug
classes. Thus, ~atypical" in this case really refers to the
unique chemical structures represented in the group. These
drugs are briefly dealt with here.
Duloxetine (Cymbalta) and venlafaxine ( Effexor ), some
times considered to be in their own subgroup, are the
serotonin-norrpinephrillf reuptakt inhibitors (SNRls). They specifically
inhibit the reabsorption of serotonin and norepinephrine
and elevate mood by increasing the levels of these agents in
the central nervous system. In many cases, levels of dopamine
are also affected with the SNRIs. In addition to being ap
proved in 2004 by the Food and Drug Administration for the
treatment of major depression, duloxetine (Cymbalta) was
approved for the treatment of neuropathic pain. Venlafaxine
( Effexor), more recently used to relieve depressive symptoms,
is available in an intennediaterelease form that requires two
or three doses a day and an extendedrelease form that allows
the patient to take the medication just once a day.
Bupropion (Wellbutrin) not only inltibits the reuptake of
serotonin but may also affect the activity of norepinephrine
I Sertraltne (Zoloft)
ADVERSE EFFECTS
ADMINISTRATION ALERTS
2..... wk
Unknown
Half~ift: 24h
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HerbilUFood: Pai:ieflll s.hoold use prrooIion ff laking St. JOOn~ WDn or Itryp! .......
lOavoid 1fI00onin sy~.
Trratment of Overdost: TheR' is no IptCm{ treatment forOY!'rdosr. [mergency
IIII'diul ntention and gtntral IUpportil't mtuurts may be 1If(~IUI)'. Symp
10m I of OIItrdost ilKludt [\jUSfil, vomiting, Irrmo~ ~izurr~ agiution, diuilll'S~
hyptractjyity, rnydria ~s, tac:hlUrdi.J, and coma.
RRftrIOMyN1!~l fIII ~ MmhjftocmForu!!pf'dt IOlhll rtII!/'
ceptors, thereby enhancing release of these neurotransmitters. Nefazodone (available in generic form only) is similar
to Remeron. It was originally designed to treat depression,
and causes minimal cardiovascular effects, fewer anticholinergic effects, less sed.1lion, and less sexual dysfunction than
the other antidepressants. Trazodone ( Desyrel) is most frequentlyused as a sleep aid, rather than as an antidepressant.
The high levels of trawdone needed for the amelioration of
depression cause excessive sedation in many patients.
BIPOLAR DISORDER
Once known as manic depression, bipdar dilorder is characterized by extreme and opposite moods, episodes of depression
that alternate with episodes of mania. Although patients usually experience extreme episodes, periods may shift between
_Frutts
....,
..
Rai~ns
Datry Products
Akohol
"",
.,.,
Sourar~m
M~"
SMOfdimn i'lff
Pat~
Me~t9tOOI
(anned/igl
Prppfrooi
Salami
""""
BobJI.ilhot dogs;
Vegetables
Sauces
So)' WlKf
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189
Yeast
,I,llymtOf)'ust9!1Kll
Chocolate
I Phenelzine (Nardll)
ADMINISTRATION ALERTS
WI>lIOUI ~~. of 2 to) wt~ks I .. J<quired bolo .. imrodueing orhor
drugs.
Abrupt disrontillJition of this drug rna)' caus~ .. brond hypffit'nsion.
Pr<goanq category (
ADVERSE EFFECTS
Common side t1Fts I~ rollltipation,dry mouth,orthostatic hypot~nlion, insomnia, naUIN, and Iosl of appetit~.1t may illUNlI' hei n ril1~ and neural activity,ltadiog to dtlirium, mania, InriHjo, and roovuisions. ~ hypenemion
may occur when ingtStiog foods containing \ylimine. Srizurt'l, rtSpiratory d~
p~~n,cil{ulatory (oIlapll'"nd com, may occur in calrl of ~etI' ~ert\Iu.
(ontraind ications: Patitnts with cardiovalrular or (ert bmra !(uiar distall', h~
pili< 0/ JPIl,1 imp"inn~nt,~nd phParhmmorytnnu ",..,Id not '''''Ihi< dnHJ.
INTERACTIONS
1Wg-1Wg: MiIIrf othHdrugsiflKt thriKlicrl 01 ~~.(on(u1fnillll' 01
tritydI: ilntidfpmsants ind SSRk IhoUd be iI'IOidiod bKNIe the (ootilation un
<aII1f tl'mpffatln ~aIion mwtm.()piates.ind:.ting IlK'pfridiDf,!ihcUd be
PHARMACOKINETICS
()Jsrt: 2Wftks
Pei k: V,riablt
Half~i~:Variablt
Duration:48-96h
extremes, or there may be prolonged times when mood is normal. Depressed symptoms and slightly depressed or dysphori'
symptoms are the same collection of signs as are referred to
earlier in this chapter. Mania is characterized byex>:essive
e NS stimulation that results in symptoms listed in Section 16.7. To be diagnosed with bipolar disorder, manic
symptoms must be present for at least 1 week. Hypomania is
characterized by the same symptoms, but they are less severe.
Mania and hypomania may result from abnormal functioning of neurotransmitters or receptors in the brain. Hypomania may involve an excess of excitatory neurotransmitters
(such as norepinephrine or glutamate) or a deficiency of inhibitory neurotransmitters such as gamma-aminobutyric
acid (GABA) ('hapter 1500). It is important to distinguish
mania from the effects of drug use or abuse and also from
schiwphrenia (ch.1pter 1700).
16.7 Characteristics
of Bipolar Disorder
During the depressive stages of bipolar disorder, patients
exhibit the symptoms of major depression described ear-
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lier in this chapter (section 16.1). Patients with bipolar disorder also display signs of mania, an emotional state ,haracterized by high psychomotor activity and irritability.
Symptoms of mania, as described in the following list, are
generally the opposite of depressive symptoms:
- Inflated self-esteem or grandiosity
- Decreased need for sleep (e.g., feels rested after only
3 hours of sleep)
- Increased talkativeness or pressure to keep talking
- Flight of ideas or subjective feeling that thoughts are
racing
- Distractibility (i.e., attention too easily drawn to
Wlimportant or irrelevant external stimuli)
_ Increased goal-directed activity (either socially, at
wurk ur ,druul, ur ~.,.... ually) ur l"y~huJHulur
agitation
_ Excessive involvement in pleasurable activities that have
a high potential for painful consequences (e.g.,
unrestrained buying sp rees, sexual indiscretions, or
foolish business investments)
191
Assessme nt
ore
lneflmift CGping
.....,.,~
ArtJiety
Ois~ Jhought i'nxHIfS
Sleep p.Utm Oisnrmrl(e
~runtSflf.u~
o Imb.rlan<td Ibrition, Morf or lHs Than Body Rfqui~~B
Dysfunc:liorwl Grining
Sociillsolation,lmpairfd SoOaIlmer.lI(tion
Aktrtd Flmil, '~1fS
UrNI)' Rtttntion (reIatf<l to .ntkholintrgic tift(B oIdnrg therapy)
Noncompl"lolnce (INted to ~ drug t l'lKu oIdt(fl'ol\fd Sell1i1lli1do
illldlorwtightr;.i11
~runtKnowItdgt(drug~)
Risk for ~H-1irKtrd Violence, Risk for ~If-Mutiation, Risk b Suicide, Risk
me
lor kt,iJ1)'
AssHsmrnt throlghllUllckninislration:
AlWSs fordnim:! tlifllpMic tHem (t.g., rot. sed mood, Insenilg
dtpIession, inueastd '(Iimy 1e\oeI, retum to norm.1 ADiJ.'l'Ptlilt .nd
swp patteml;if IIII'd for oIMrlMl,t.g., llfllropathic pain, .sms for
awropri.ln tIwf~peuri<: ~).
Conlinut periodic monitoril'lg ofeBc.~es. glucosc.and hepatic .nd
ruwl function studiH.
AslfSs vital $iI;11l'J .nd WI'igbt periodicily 01 as sympt_ wanant.
AlSfIs for.nd promptly rtport .dvtnt rifms :diaintss OIlighlhudt<! 1ItU, drowsiness,. confusion, ac;utiln, suicicLJl idrnion~
pilpilations,. U(ltyardj,,1H.md or double "fis ion, skin ll'lbes, bruising or
bleeding. .bdomiN Ipain, jllII1dice, d\allgt in color 0111001, flank pain. mel
hrm.turia.
Implementat io n
Inte rven tions and (Ratio nales)
Ensuring thel'ilpHtk effects:
Continut .mfSSmtnts as dewibtd t . rlitr lor tIwr. ptUtir t trls. (Drugs
us.td fordtpmsion IIIiI)" take 2to 8Wftks befo~ fuR rfffma~ ~.ilrd.
Use objKtit mtalUrH,t.g., IIKk Dfprtlsion I~ntol)'; whm possiblt to
htl pqua rIify tlwrlptUtic: reults. For outpitient thmpr; JRl(riplions m.~
lit limitf<l to 1&ys' worth ofmtdiwion. HaI't tht patitllt sign a"No
HarmlHo SUcicIt"contrKt uappropriatt. When ustd lor iIIIxittyor
insomnia, nonpharm. mIogiI: mt.mlrtllllilJ be netdtd until lilt drug
rmhes fuI rifms.)
.....
o 1NdJ tht patiennhat lull rifms 1IIiI~ not IKrurfor a prolongtd ptriod of
bne but thilt ~ imprvmntnt v-.oukl be noticra~ .her beginning
Enc:ourlgt 1M p.i6tm to Io:ftp .applintmtnrs with the thtllpist.nd III
dilruss 01190 iIg symptoms of deprtlsion,!epOfIing any sUOcM Iideatiom
immtdiatt ly_
(Cootlnued)
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192
INCh tilt, pailiffl: II rin from lying or lining 10 nanding dowIr 10 avoid
oizzinessorf&
Instruct the patimt to cd for iSsistanc~ prior k! gt'lting out of bed or
alt~pting to wal alo~, .J nd .. avoid drimg or other actiritin ftqJDIg
mtnQI.ltrtness or ph)'!iul coordination lind rifNb of the drug II!
....".
Instruct the pitient on the ~ k! retum period ically for bob WOIk.
TNCh tilt, pailifnl k! promptly rtpMt any .Jbdominal pain, partiarbrly in tilt
upprI' quaclrinu,dJinge1 in stool (010~~ 01 Idm orstin,or
~urir.e.
~Iffi
hNdicflt. dizzi~lS,
Tth tht paitirnt ~ 1M itt dJips, frtqumt sipsofw.ttr, 01" cMwing glm or
bard candy to alfNt~ dry mouth and to noid lIkohol-bistd mouthWilWs,
which miYinot.l:!e dryness.
U~ of"dry ~" cI!cps.nd mUng f)'e5 ptOO:fruly l1li)' h~1p to dKl9K dry
rJ! ~in(j. TNCh tht ,..tienllO report ,IllY fmirJgs 01 I(IlIIchines!or~
pail immedi.ntly.
.,....
mel
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0I0p1fll'
193
....
commonlyobstMd~e&m,p.lIll~bwhento(il thehe.khu~
~andu'1 ~'1 moritori~or prmutirn..(lkingtimt<k.ring
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19 4
Unlll Thl'Ne<voo,Sy'tem
ithum (Esulith)
PO;
ANTISEIZURE DRUGS
Adverse Effects
drndatro (ollapsr
Ylbimazrpil~ (T~oI)
lamouiginr (LAmmi)
(max:7oomglday)
valproit i(id (Ilrpaktnr)
(~~176Ior~
oIanzapinr (1)'III'W)
quetiapiDl'fl.mara!~
(~I)
zipra~donr (Gtodon)
Tildrjcorriia, /folUitnl (eM!!; iWlrion, tlzil1fI~ IINdlKht, lighrfrtadedflru, lOfIlOOItlKt, OflOOy, ntrl'OIIIIltIS, Msriiry, inIOmfiQ,
11011~ I'Omirilg, rorurip<Ili9l1, ~killJOfiIlll, okorMio
I Lithium (Eskallth)
Ahhough t~ ~oo mechanism of lion is oct (IN~ ithilm has been thought to
alter ionK activity and tilt activitifS of nrulOOS rontairing dopImiDl', norrpinrphriOI', and Sl'rotonin b)o inftuenc:ing their ft'1NS!', synthm,and !tI4llau.MOfI' I!'(mtuudifS!IJ9I}tII thnlithium may inhibittht anionofgwmate;.JnootalOl)'
neurotransmitter in tht syn.I jISI'. Other promililg infonnation indKatfi that Sl'rotonin it the r~tor may ~ bloded and thaI ~ syntIIaSI' kina~l beta
may be inhibittd within liMo nruron.TheSI' ani:msl!nd 10 stabiiIr a widtr ra~
of (elkJlar tlllnsc1ucti>n pathways. ihtraptUlK KIions aft' ~abilimiJn of mood
durilg periods of mania, and amideplt'SQ nt ~tre.:n duriIg periolk of depll'Ssion.
LithiJrn has nrither antimanit nor amidtpres.ant propertifS i1 indivWals who do
not ~ bipoiardisordtr.Afur taking lithium for 110 3 __ b,~tifnts shooJd be
abl!o to bener (Onc~mrab.' arod function in ~-<.ift'.
l)ug-Drug: Solllf 00Jgs iIoNIe thf IOO! oJ! wIith tht on,s eo:M' IiIhUn from!ll>
tbcIsUYn, ~ dW!ics, IOIi!Jn biIartIOOatf,R/ pclassiIfn dlOO!. 0!hI'r 00rgs,
ADMINISTRATION ALERTS
lithium has.J narrowtherapeutidlou.: ratio; the risle of toxicity is high.
Acute o'mdosaqe m.JYbe UNiN by h~modialysis.
ilNn,ma,GlUSI'afllldQlemergerqNrold<anpdl'llliiltfdrugarnn
Prrgnancy categPl)' 0
IIfrbaVFood: Unknown
PHARMACOKINETICS
IAlset:S -7da)'l
Peak: 10-21 days
~M:lI)-17h
Duration: Varia~
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~dfll9lt.Iltilllfllinal)'lfImoo!hat,nqElwi:b!ll>jUl)vi.Jf&aof
195
Assessm e nt
o Anmt)'
o DislurbtdThought Proc:e stS
o SftpPatlemOisturban(f
DerKient Self.{all'
o ImbilalKrd flutrilion,More or ~s Than Body Rtquilt'flll'flll (rspeciall-;
!Odium)
o SocialilOlation, Im~ill'd Socia llnleraction
o Akell'd Family Proc:HStl
o OtrKient KnowIedgt (drug therapy)
o Risle for Stlf-Di!ro~d YiolelK~, Ri!le for Stlf-MUlilalion, Risk for Suicidt, Risk
Iorlnjury
o TNCh the ~tirnl thu full tffNII flIiIy not O{(Ur for Sf'll'fal Wffkl bul thu
10m!' imp("{I'Hm!'nt should ~ notictable aittr beginning thtr~py.
o [1l(ourage tht patient 10 keep ill "ppoinlmenu wilh the therap~t and 10
disrusl ongoing symploms oIdtpll'Ssion and mania,and immtdiattly
Il'pOI1 any suiciclal idtations.
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19 6
Until Thl'Ne<voo,Sy'tem
Weigh the patitnt diily and ~pon <I Might g<lin or IoSI of 1 kg
(appro:.:imately 21b) or more in a 24-hour ptriod. Mmu~ imakt and
output in tho hospitoliN<! potion!. (o.il~ _ight is on >u"t. "''''U~ of
Hoi!, the
Ia"'.
uri~outpul. hematuria,
or urine Itdimtm; IoWt'r abdomin.ll tendemm or funk pain; naUlti;or
diarrhea to the heakh <are provicll'r.
disNs~.)
The patient should bt able to state tht IN.on for tho drug;'ppropriate dOl.
and IChtduling; ,nd what adYers. effr(l\ to ob\eI"W for and when to rt'port
,t.m.
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PHARMFACTS
~al3,
and
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197
198
Unlll
TABLE 16 4
Tt~
/IIe<v"",.
System
Adv~rse
Arldefal~XR)
bmzphe~int (DiRx)
dexmmyiphtrida:t (Foolin)
DN'
Effects
eNS STIMULANTS
(Duedrintj
dn:wtory
(a l!Oa"liila~t al ~roStatand
Dmdrint Spm'*,)
i ldwmftlilmintl'o'ylall!o!)
methamphetJmilf {Dffix)"Il)
I Methylphentdate (Rltalm)
ADVERSE EFFECTS
INTERACTIONS
I)ug- l)ug: ~idolf illHittl with manydnJ9l.FIX" mmplt, ~ may
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~ ~efIKti_lof anticorr.Ulanll,anticoagwnll,andg~1II'.
1"
Assessment
Und!'nund lhr INson the drug has ~n pmcribtd in orDtr to mes for
thmptUlic: t1FfCts.
Obtain. compitte i1Nhh history including hepilic:, rtnilCirdio'l~lOJlitor
naualogi< dilNlr, including ~leply. Obtain. drug history including
allergies,eurmlt plfl(ription ~nd Ol( drugs, and hflbal pl\'par~tioltl.1k
alert to pos~bIr drug intemtionl
Obtain I IO(gl and bthivioral histo~.UltobjeaiYt S(lttning tools when
polSible.
Obtain. nutritional history.nd HIfIS norm. 1~p paltrrns.
Obtain ~selinr vital sigm,.nd heighund weight.
E~luate appropri.nr l.iboratory findinqs (e.g., electrolytr~ (BC hepatic:
and mlil function studies).
AslrSs the patitnt"s ability to re<tiYt.nd undtrsUnd inltnKtion.lncludt
the family .nd {.~i",,"s as nerdrd.
AslrSs for dt~red theriptUlic: e fie<u (e.g., incrt' sed ability to focu~
normiliud i{~vity Ieels with lesltned impulsivity, maintfllantt of
norm.1 i ppetitr .nd ~p paltrms).
Continur periodic: monitoring of rittlroiytes;, (BC"md hepatic: and I\'nal
~nction truditl
(ondnur to monitor vital sigm, .nd height and wright wttkly.
Assess for.nd promptly I\'porI idftntffie<b:dizzinrlS, lighthNdrdntl!,ln~,lgiuotion,fJ(rlliYt phySic:.tIICtivity, t.drfurog,
inclI'asrd blood p!ffiUr~ h)'ptrtrlllion,.nd palpitations.
--+--
(ontinur to monitor the PUM Ind blood plI'SlUR'on hrakh caR' visits.
(lachyurog,in{R'm blood p1rSIlJR', or hyptnrnsion may occur if lhr
d= is el{fSsWe.)
TriKh the pltiem, family,or wegivrr totae thr puMalong wilh Wttkly
hright;rnd Wfight or all)' time symptoms warrant (t.g. child (ompl.iim of
chest disromfort or pa Ipit.nioltl). Almt the patient. family, or (aR'givrr to
find PUM Ioc:ation mOlt Mil)' frk and hm the ~titnt. family, or wegil'tr
R'tum..:frlOOllllr~te pullt taking beioll'going homr.
Wrigh thr ~titnt wtt'kly .nd obtain the patitnt's height.lleport .ny
weight loss orfailuR' to ga.in weight during thr txpKIrd growth ptriods.
Assess nutrition ind 1M of other slimul.iting prooiKts (t.g:rlH'!9Y
drinln, (.ffrinatrd be'l"rrages). (Diminishrd appetitr or ;r norma from
stimulating effts of the drug, or 1M of othrr sli rrul.inn, may impair thr
normal nutrition nredrd for growth and dtvriopmrnt)
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200
Unlll Thi'Ne<vDI"Sy'tem
kl('S, the Iftd for rominuous medK.-ttion or I'ftd ilr dIU] holidays with th e
pat~nt f, mil)o. ca~iI'I'~ and health we PlU'fid!'l baled on the
lO{iaVbeh.J'Iior,1 diart findirtg!.(Dtpendent on tlltdtg""' d~ drug
holidays 0I'!'f oon---smool days or VoKiltion periods may he IffimmendedJ
kll'U the oome !'II'Iironllll'ntfor medication \ilfMy and the I'ftd for
,ppropria~ intl'M'lltion ~ Mvile the fam i~ on II'StrKtion, about
prescription lI'IWWal.(Methyiphenidate is a Scherule II drug ,nd lIIIIy oot
bt UII'd by all)' other peoon than the patient Saf~rd mediution in the
oome to pll'Vfllt ovenlolagl'.)
The patient family. or ulI'giver ,hoold bt ,ble to stile the ~a50n for the
drug;approprilltt doll' and Kheduling;.Jnd WMt ildYl'lll' efferu to obII'lI'I'
for ,nd when to ~pon.Jnd when to II'pon them.
"t
The main treatment for ADH D are CNS stimulants. Stimulants reverse many of the symptoms, helping patients focus
on tasks. Drugs prescribed for ADHD include D- and l-amphetamine racemic mixture (Adderall), benzphetamine
(Didrex), de.:'l:methylphenidate (Focalin), dextroamphetamine (Dexedrine), lisdexamfetamine (Vyvanse), methamphetamine (Desoxyn) and methylphenidate (Ritalin).
Intennediate- and longer- release forms of methylphenidate,
marketed as Concerta, Metadate, and Methylin, are avail able. For greater flexibility in dosing, a methylphenidate
patch marketed as Daytrana was approved by the FDA in
2006.
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Patients taking CNS stimulants must be carefully monitored. CNS stimulants used to tr""t AD HD may crute pu_
adoxical hyperactivity. Adverse reactions include insonmia,
nervousness, anorexia, and weight loss. Occasionally, a patient may suffer from dizziness, depression, irritability, nausea, or abdominal pain. CNS stimulants are Schedule II
controlled substances and labeled as pregnancy altegory C.
Methylphenidate abuse has been increasing, especially
among teens who take the drug to stay awake or as an appetite suppressant to lose weight.
Non-CNS stimulants have been tried for AD HD; however, they exhibit less efficacy. Clonidine (Catapres) issometimes prescribed when patients are extremely aggressive,
acth"e, o r have difficulty faUing asleep. Atypical antidepres-
Li fESPA N C O NSIDERATIONS
_1Oftd.
KEY CONCEPTS
The numbered k.-y concepts provide a succinct summary of tile Important polnls frolll the corre5pQndlng numbered section
within tile chapter. If any of these points all' not de:.u. Il'fer 10 th~ numbered sectio n witllin the chapter for revM'w.
16,1 Everynurwshoukl bf, proflcltntln Iheassessment of patitnu with signs of depreaion. Dep.-eWon has many
forms and chal1iiCleristlcs.. and 115 identification and etiology areessenllallOr propel'" Ill'atment.
1'-2
163
SS Rls act by selectiVely blocking the reuptake of 51'roton in in nerve tennlnals. Ilec:aUSf of fewer side effects,
SSRI5 are drugs of choice In the pharmaCOl.herapyof de-
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lU
202
Anticholinergic effects are common adverst' effects of an tidepressants such as imipramine (Tofranil). These effeds
may include:
I . psychomOiorsymptoms.
2. tachycardia, hypertension,and increase in respiratory
rate.
3. tardive dyskinesia&.
4. blurred vision, dry mouth, and constipation.
The parents of a patient receiving methylphenidate (Ri talin ) express concern that the heal th care provider has
suggested the child have a "holidayn from the drug . The
nurse explains that the drug-free holiday is designed to:
1. reduce the risk of drug toxicity.
2. allow the child's "normal" behavior to return.
4. prevent hypenensivecrisis.
2. 1 wt't'k.
3. a month or longer.
4. within 24 hours after staning thedrug.
3. A 26-year-old mother of three children comes to the prenatal clinic suspecting a fourth pregnancy. She tells the
nurse that she got "real low" after her third baby and that
she was prescribed sertraline (Zoloft ). She tells the nurse
that she is really afraid of "going crazy if she has to stop
taking the drug because of this pregnancy. What concerns
should the nurse have!
EXPlORE
Liitlll11fufiIt3!fiJ-----,
"",Jltr.:irlgKit Ig )'llll' ooe stop lor Min e ~h1~er IIMeIr.I maffirials BOO
resources. I'rejla(e Ioc suCQ!;S Wllh addjlimal N C~,stytr practJ~
~ Iyjties ,
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DRUGS AT A GLANCE
LEARNING OUTCOMES
CONVENTIONALANTIPSYCHOTICS
Phenothiazines 1lUJtlO5
pagt.ni
Q chlofpromal1nehydrochkNlde
(Thofazlrw) fXXJl ](JJ
Nonphenothiazines plJlJOllJ
Q haJopmdoi (Holda/) plI}t }(M
ATYPICALANTIPSYCHOTICS
pl9t}(18
r/spefIdone (RJsperdaJ)
{II1Jt m
plI}t 1I6
KEY TERMS
akathi5ia puJl105
delusions page](J4
dopaminr type 2 10,1 rueptor pi1tjt}(H
dystonia flljl 106
utrapyramidal sidr f'ffects (EPS) (X1IJt lO5
hallucinations {llXJt lO4
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pot}f ~
204
Unlll
The
/IIeIv"",, System
PHARMFACTS
'7.'
SCHIZOPHRENIA
Sdtizophrf nia is a type of psychosis characterized byabnormal
thoughts and thought processes, disordered commWlication, withdrawal from other people and the outside environment, and a high risk for suicide. Several subtypes of
schiwphrenic disorders are based on clinical presentation.
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Psychoses
Sjrmptoms of psychosis .reoftm moc:iatfd with othtr ment.1 hNlth
problems indJding subll.nc:t .bust,depmsion, .nd dtln!'ntia.
~)'(hoti( disorotrsare .mong tilt moll misundtmood mtntal htalth
disordeB in North Amerita.
Approximattly 3 million AflII'riufIS havt !(himphrenia.
Patients with ~)'(hOi~oft~ devtlop symptoms brtween theages of 11
.nd tht Nrly lOs.
As many as SO'Ibofhomeles peoplt in Amtriu h'Yeschizophreni .
The prob.;obilityof dtYOlopi!ll) I<hizophruia ~ 1 in 100 for tht <Jl'llffill
population, 1 in 10 if one p.llent has the disorder,.nd 1 in 4 if both
partnts h.M I<himphrenia.
CNplfr17
ON9'/orPsycho ... ,
205
.ad.. ta
"
Dopamine
.....
synapses and competing with dopamine. By blocking a majority of the D, receptors, antipsychotic drugs reduce the
symptoms of schizophrenia. ,.. Figure 17.2 illustrates antipsyt:hotic drug action a\ the dopaminergic receptor.
Sc:hizoaffl!Ctivedisordtl is a condition in which the patient exhibitssymptoms of1:oth schizophrenia and mood disorder.
For example, an acute schizoaffective reaction may include
distorted perceptiotl'l, hallucinatiotl'i, and delusions, followed by e:rtreme depression. Over time, both positive and
negative psychotic symptoms will appear.
Many conditions can cause bizarre behavior, and these
should be distinguished from schiwphrenia. Chronic use of
amphetamines or cocaine can crealI' a paranoid syndrome.
Certain complex partial seizures (chapter 15010 ) can cause
unusual symptoms that are sometimes mistaken fo r psychoses. Brain neoplasms, infections, or hemorrhage can also
caufoE.' bizarre, psychotic-like symptoms.
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\ :.
~
Dopamine (0,)
. ,",,~
i
>
Postsynaptic
~~
206
Until TheNelv"",,Sy.rem
psychoses as well as Parkinson's disease nero an antipsychotic with minimal extrapyramidal sid e effects. Those who
operate machinery need a drug that does not cause sedation. Men and women who are sexually active may want a
drug without negative effects on sexual interaction. The experience and skills of the physician and memal health nurse
are particularly valuable in achieving successful psychiatric
pharmacotherapy.
Phenothiazines
The phenothiazines are most effective at treating the positive signs of schizophrenia, such as hallucinations and delusions, and have been the treatment of choice for psychoses
for 50 years.
"n"
o ddpromazine Ha (lhorazile)
ptIjI/Irnazinr (Phrnazilr,Triafon)
proddprrilzinr (CompalinrJ
trift~azine Ha
as Strlizilr)
l0ri9naliy markrlrd
Adverse effects
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CNplfr17 Oru9,lorJ>,ydl<'''''
207
Dt>sc~pllon
A(U\! dyltonia
AkaltilU
AntidlolintrgK dftcts
Hypoll'fl~on
IIN'oItplk maligr.antsynd~
Parkinsonism
SIodi~on
shuffling ga~
SIoml dysfunaion
1Irtift dyskintSia
BizaITl' lOII9J!' and loa mlWl'fIIenllsum " lip smading ind 'IIOIIIIlike moIioos 01 tilt l~; puffing 01 dims. unrontrolltd
dltwing mO'ffllln'l1l
ADVERSE EFFECTS
Chlorpromuillt plVt'ides symptomatic: R'lief of positive Iymptoms of s(hizophlfnia and controls manic symptoms in piUenIl with schizoollftcti'fl' disordtr.
Man, pilients mUlt ukt chiorpromazilll' for 7 or 8 weeks bfflllt' Ih~ up~i
t nct improl'l'mt nl Extmnt 'gitation may ~ IrNttd with 1M or IV injKtions,
whkh ~gin to mwithin mirutts.(hlorpromazine can also (ontrol ~ nauSN and Of11iting.
Strong blockade of alphNdR'ncrgic: Jt<eptm and weak bloxbdt of dlOliocrgk ~fpton upliin somt of dllorpromazinf'l ad'fI'M efrecu. Common ,d'fI'~ tfftm 'If diuinm. drowsintll, and orthostatk hypotension.
ulUapyrlmidallide tfftru (EPS) occur fIIIR (ommonly in tldtrly, female,
and pediatric p.atitnu who alf dthydrated. Neuroleptic malignant syndromt
(NMS) may also ocrur. Palitnu taking chiorprom'zilll' who alf ~POSfd 10
warmtr ltmperatulfsshould ~ monitortd more (J,uly ~r symptoms ofNMS.
Contraindi (itions; U,t is 001 advised during akohol withdrawal or wlltn tilt
p.atitnt is in a (omatost slate.uution should bt lntd with other conditions, induding ,ubc:onic.J1 brain damagt, bolll' marrow dtPlfllion, and IIt)ot'S 1)11drornt.(hiorprornazilll' is conlr<lindk,ted in 1.Kution.
ADMINISTRATION ALERTS
PHARMACOKINETICS
INTERACTIONS
DIIII}-DIIJ!I; (hIorpromazi~interam wi!lllfWlai dll~.F ~,conCU"lfnt
UII' wi!ll IfdaliH m"imions IIKh as p/IfrII:t.rbitJI shcU:I bf iMlided.latilg
chklrtromazilf wi!ll uiqck Intidfpresam uo elmu bbod prl"llUIf. (1IKIIIfffl
UII' of (hlolpromazioc with illlistizlfllM:li:ation uolo\m" lilt wuu tImhokI.
li bTesll; (hktpromazi~ mil')' ilKlNl! <lphaIin ftoccul.nion and ~ibIy O!h@r
lim function Ifill. Fall!-jHIIiliw Il'IUhs may om. for anyIast, 5-~lOIyioo
iCf!ic: add, poiphctIi~OOJI'fII, urobiRlgfn,and ..... bilirWin. FoJM..posilil'l' ...
faI ....!If9OtM Pf"9'IOIK)" !tm may ,..ut.
Hm VFood; (.wa ind StJohn\ won may OO&I!I' lMrist and lfWIilyoldystonia.
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nia without producing some degree of extrapyramidal effects. In these paTients, drll8 therapy may be warranted to
treat EPS symptoms. Concurrent pharmacotherapy with
an anticholinergic drll8 may prevent some of the extrapyramidal signs (chapter lJOO ). For acute dystonia,
benztropine (Cogentin) may be given parenterally. Levodopa (Dopar, Larodopa) is usually avoided, since its abilityto increase dopamine function antagonizes the action of
the phenothiazines. Beta-adrenergic blockers and benzodiazepines are sometimes given 10 reduce signs of alca th isia.
Nonphenothiazine,
The nonphenothiarine antipsychotic medications have
equal efficacy as the phenothiazines. Although the inciderKe
of sedation and anticholinergic adverse effects is less, t;[trapyramidal effects may be COOlmon, p3rticularly in older
adults.
~ Prototype Drug
nothiazines is identical with that for the phenothiazines, although the degree to which a p3rticuLareffect occurs depends
on the specific drug. In general, the nonphenothiaziIll.'drugs
cause less sedation and fewer anticholinergic adverse effects
than chlorpromazine (Thorazine) but exhibit an equal or
even greater incidence of extrapyramKbJ signs. Concurrent
therapy with other CNS dt>prl.'SSants must be carefully monitored, because of the potential additive effects.
Drugs in the nonphenothiazine class ha,e the same therapeutic e ffects and efficacy as the phenothiazines. They are
also believed to act by the same mechanism a5 the phenothiazine!. that is, by blotking postsynaptic D2 dopamine re ceptors. As a class, they offer no significant advantages over
the phenothiazines in the treatment of schiwphrenia.
Halopertdol (Ha/dol)
thi! inc:idtncr of EPS is high. 0Idfr aduln IrI' mOIl' IirIy to O"pmmc:t ~
tftects .nd oftrn art pttSCribtd hilf tilt icLiIr clost until tilt ~r rifu of
thenpy (In bt dtttnnintd.Although thi! inc:idenlr of NMS is r.lrI', it can occur.
ADMINISTRATION ALERTS
Do lICK ilbrupdJ lWonmue,OI_ aMB!' ~actiom maYO(rtII".
TIlt INtitntllMt
IODtOIr.
If 1M patient dots not (limply with or.1 thrrapy, injectab~ attndedRluSf haloperidol shlDcl bt (OfI~
Prf9IIiIKY Ulf90ry (
PHARMACOKINETICS
!met 3O-lSmin
Puk: 2~h PO;lO-20 min 1M
HalHiM: 12- 37 h PO;lO-19h 1Y;17- 1S hIM
Duration: VoIrwbit
(l)fQnilg ifUCids, \rIo6opi (., ilaN~ dlill<fS 111 ItlOdopa 1OIicty), itmn
tilaNledlloo! 111 a_r lllUcMMj<tQ[m,),~p/ItaJIoin (.,
iIIaNsts m.e of p/ItQJtoin tolid!Jl, rf.... .-.d bt\.J iIIIICbrs~ iIuNSf
tIIood lewis 111 I\aIopf!idoI.lhus INtifI9 to podIII! lOIm,lllalo9tridol inhibits 1hf
.riInof(~ri"IJ~pMtn!iws.
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RoIpI.,11 OtugsforPsychows
209
"'''''
cHo!pothixmr (brawn)
Adverse Effects
PO;Ol~S mg
Ofthostlltt IIyptmiaI
bid or tid
1M : 2~SmgMIY4h
HCI (Mabin)
pinozide (Orap)
thiothilene HO {Haoantj
Assessment
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210
Unlll
Th~
/lle<vOI" Sy'tem
Implementation
Interve nti ons and (Rilti o nll les)
En suring thfrilpeutic tfffCts:
CominUl' illStnmtmS iI,decribtd tarlit"! lor thtraptUtic tlftcn. (DIII9'
lMd for p')"hO<t< .nd I<hizophffnio do not (Uff tho undtrlying di,,,",,,,
but implO'/t pcnitiv. ilnd ntgati~t 'ymptom, of the disorder. Gradual
improlm\ent o~ Sf"Ieral wtt'H to month, may lit oot.d)
IIIYOIvt the famii)o and (al!giver to the flIent pos~bIt in l'IIwring tilt
patitm I!mains on rt'9Ular mtdirnion rootiOfS.
EIl\UI! that the patitnttakl'S tht mtdication as prescribtdlkm It~
mtdication, at the btd,idt.
Quetion tht pos~bilityof oonc:omplianct ~ original ,ymptoms or advt~
tflKn !Udclen~ inclNM' in ifl'quenq or ,tytriry.
Ha'lf the patitnt riM' from lying or sining to ,tanding !Jowl~ to ilwid
diuineuor falk.
Instruct the ~ient to Glillor mimnct prior to getting OUI of btd 0/
anent pting to walk il ion . For patient> on at -homtloutpatitm mtdication,
awid driving or other acti~itits requiring mental "ltnOfS,or ph)"lical
coordination umil tlfKh of the drug "It' known.
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a..".. 17
NURSING PROCESS FOCUS
OruglforPsychoses
211
\/lUI'"
phOllenWlCy.)
Mon~o!for Moho! and iIIegiI drug lM. Clked con<lIIft'IIti); these ause in
irroeilsed OIS~l.int etft or In o:acerbation in ~tic
IIIIWCI the ~itnt to aYoid ,Icohol ,nd illtg,ldrug 1M." tilt patient 10
community IUpport groups sud! ill M or HAiIIlppropri.tr..
I)'II1ptom~
---"---+---'
The ~tRn~ fimit:or u~ should ~ ibIe tonate thr fI'iIIOII for the
d!urJ;ilPPIOpriiltl' ~ and sdwdrling;and whit ildYerseefftl tOOWM
for iltd when10 ~ thtm.
kiluate the tftitiJene!1 of drug ther,py byamfinning that ~tRM goil! iltd txpted goal! have ~n mtl (leI'i'lanning1.
5tt WlIeIII.' RIllJ kf isD tI.tug5rott1idtrbtMlIII~II1fi111Q~
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212
Until
Th~ /lle<vOI"
Sy'tem
~ Prototype Drug
Rtspendone (Rtsperda/)
medil~tions
to
Plf9nancy category (
PHARMACOKINETICS
IAtSl'I:
Peak:
1 ~2wkPO;lwkIM
4~wk
Half~ifdOh
Duration: 6wk
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ADVERSE EFFECTS
Common adRr~ efftlts aR' Htrapyrimidtl R'aions (involunury shaking of
the ~Id, lH'Ck,andanm),hypmcril'ity, fatigut,naulu,diuinm, viswldirturbanc6, ~I'f,and orthosUlil hypotension. Risperidolll' mil)' (1= Wl'ight gain
and hyptrgl)l:fmia, thus wolltlling gllKoSl' comm in diabetic patients.
Contraind ications: If older adults with dementia'R'liIted ps~ are giW'll
risperidone, they aR' at an increa sed risk for ~art failure, pneumonia, or sudden
death. Patients with undtrlying Iol rdiov;J sru1ar diSl'~ mil)' lit fljltCially prone
to dym)1hmial and hypolension. RilperidOlll' should lit lroided in pllieml
with a history of Sl'izurrs,SoUilidtl idutions,or kidlH"/lIivrrdistaSl'.
INTERACTIONS
1Wg~1Wg: PoJli@nutaking rispmIorII' IlKUdMid(HS~u sum IS
akltool, anllh'ltMlUnrs, INaWH"oypnoro. or 0JI0icI analgeln I/l!"S.! can IIImolSf
100M' of the IJdI'l'l>! ~ of rilpfrid OM. 0... to itjbitirn of il'H fIll)'1Iti, O!htr
trugI that inm.u adwr;e eIf~ of rilpfridolH' indOOf SSRh SIKh as parolElilf
lPaliO,l1ralinl' UDIofIJ, and IkIol1linf lPro/Xl and antifoogal drug! sum il
IkIooazoIf mfllKan},itroKlWlaZOlf l5p<fanoxJ, and u llKOllaZdt l~izoraIl.
~ en.., ittrhn withflimiwlion by the kid~ofdolipilH' KlwriO,
whidl a1O ifl(r&lIeI the risk of advtrw rN11ion~
LableIS: RiIpfridoIH' en.., (oJIIII' iOO"UIfd II'IIIIl prolactin It"Il'Ii and ifl(JMfd AU
l~nilll' aminotranftrNl<fI andAST lalpilrtate illlinotrmerNl fti'I Ml)'lllf
IMII.Othtr poIMtiai Lib (IlangtS art iftIria, thrombor:)loptrlia,1M1K)'IOIis. and
koIi(ffllia.
TABLE 17.4
0""
Adverse Effects
aripiplalOlt (ADlify)
donpnt lClouri)
PO; run at 15- 50 mgldoIy and titrit~ to a tal9tl do~ oil Sl>-4,O mglday
in 1dol)'\; m~ i1ma~ furthe- (max;900 mglday)
Ad!lt; PO;run with , -10 mgldar. may ilKll'aII' by 1.5- 5""l ~~ wtd!
(range 11>-15 mglday;madO mglday).GffiatricPO;lt.lnwith Smg/day
PO;6mg1day (max; 11mglday)
oIanzapilll' [Zyprm)
paliptridolll' (lfMgi)
quetiapilll' fumarate (S6oqueI)
PO; 14""l bid; illR'aII' by 1""l daily toan in~ial target dolt 016 mgld~
PO;10""l bid (max;OO mg bid)
lipfilidont (Gtodon)
hfodhe,fg/lr~,lOmooitoce,QnMy,
Kllllirirrg,
cmsriplllioll.lK'limonilm, okmlrilio"
~rnidI1I.l)'mploml"
Ag!i\DulocyKtlj;.rreyrPIeptic maljooant
!'t"!Id!9rM l!i!~l
PO;runw~h
Assessment
Baselinr assmmf nt prio rto administration;
Undtrmnd thr ~alon the drug hal ~n presc:ribN in ordtr to mel for
~ripwtic:dts.
DisturbedThought Promse
Disturbed ~mory PtKtption (auditory,vilu.Jl)
Disturbed Personalldffitity
Anxitty (snrft', panic:)
ImpairtdVerbal Communic:ation
ImpairN Sociallnteranoo
Intffmivt H~akhMaintffiilKt
ImpairN HolDI' Maimt narxr
NOlKompliarxr
DeflCirnt KnowiNgi' (drug therarf)
Risk for Violtrxt (stlf-dirlfd,dill'(\I1d at othtrs)
Risk for SeIf-lMilation
Risk for Disturbed Family plO(~lI'S, Caft'9iver Rolt Smin
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214
Until TheNe<voo.Sy.tem
diuinrss or lalls.
InmuG the patient to u II for as s.istanc:r prior to gelting 0lII of bed or
itttmpting to walk ilont. For patimts on at -homrfootpatimt mtdiution,
oI\'Did driving orother oIctiYitit1lt'quiring mtmal alertnrss or p~1
roordimion umil the tiff(/S of the drug ilt' known.
--+~~
Monitor for Jnd immtdiiltly It'port ~ns and symptolll! of NMS: unstable
blood pteSure,mattd ten1peraru.."diaphor~s,dysplII'i,mul(le rigidit):
loel inrontintnc:t. (NMS is a rare but potenti.tlly fml syndromt that must
~ rt(ognized and uuted immediately.)
Instrua thr patim~ lam ily, or urtgil'l to immtdiolltly It'port all)' changt1
in IevtI of cOnsOouSlltu,eltvattd ttmperalUlt',tJ(tS~Swtiling...mlt'
mu!<le rigidit)o, inc:reiStd rrspirations or !honnrss of brtilh. or
inc:ontinenc:t .
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21 5
InstllKt the patient on the need to return periodiuli)' for lab woll
Teath the patitnt to promp~y report any abdominal pain, panirularl)' in the
upper qJidra nts; (hi ngt1 in 1100 I(oIor; ytllowing of Kie ra or ,kin; da rI:ened
urine; skin rashes; Iow..gradt ~;general mala~ or (hanges in beh~vior
or ~iYity leYrI;or If<illtll orswelling aroond sill5 ofinjury.
TNdJ wdiabetic: patitn~ f~mii)',"ta~iYerto monitorthe bbxllUCJoIr ~
frequentl)' and II'pOII (onsillent elMtion, to w hNkh tall' prafider.
[Moorage ,ips of water, ic:t (hips. hard (andy, or (hewing gum to filS!'
mouth drynffi. AYoid akoholb.Jsed mouthwashes, whic:h a~ drying to the
mlXOla and whic:h the !)Mitnt m~y drink.
Ioc:reu e dietary fiber imakeand adeqJate fluid intake.
Report urinary II'tention to t~ health (ire provider prompti)'.
~rtime.)
Tmh the patitm, f~mily,or mt<)i'lmo 'Migh tht patitnl daii)' ~nd ~n I
signiliunt 'Might gain (afer 2 kg. 4 to S pounds perw~k) to the htalth
(,1re p~ider.
Monitorfor akohol and illegal drug LIII'. [Used oooc:ulTl'lldy, these c.J!III' an
intll'ilstd CNS depress.Jnt eflett or an UiKerbation in psythotic:
')'IIIptom~)
ore
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216
Until
Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not clear, refer to the nWllbered section within the chapter for review.
17.1 Psychoses are severe mental and behavioral disorders
characterized by disorganized mental ClIp.'\City and an in abilityto recognize reality.
17.2 Schizophrenia is a type of psychosis characterized by ab normal thoughts and thought processes,disordffed commWlication. withdrawal from other people and the
environment, and a high risk for suicide.
17J Pharmaoologic Jrulnagemenl of psy,hoses is diffkult becauS<' the ad verse effects of the drugs may be severe, and
p.1tients often do not understand the need for mediClltion.
17A The phenothiazines have beoen effectively uS<'d for the
midal side l'ffects (EP5) and neuroleptic malignant syn drome (NMS) are two particularly S<'rious conditions.
17.5 Thl' nonphenothiazine conventional antipsychotics hav,,"
the sam,," thernprutic appl ications and adverS<' effects as
the phenothiazines.
17.6 Atypical antipsychotics are often preferred becauS<' they
address both positive and negative symptoms of schizo phrenia, and produre less drama Ii, side effects.
17.7 Dopamine system stabilizers are the newest antipsychotic
class. II is hoped Ihatthis new class will have the same efficacy as other antipsychotic classes, with fewer serious
side effects.
A 20 -yea r-old man is admitted to the in -patient psychi atrk unit for treatment of acute schizophrenia and is
started on risperidone (Risperdal). Therapeutic outwmes
of this drug will include:
I. restful sleep, elevated mood, and wping abilities.
2. decreased dl'lusionaJ thinking and lesst'ned
auditorylvisual haUu,inatiollS.
3. orthostatk hypotension , reflex tachy,ardia, and
sedation.
4. relief of anxiety and improved sleep and dietary habits.
Nursing implications of th e administration of haloperi dol {Haldol} to a patient exhibiting psychotk behavior in clude which of the following! (Select all that apply.)
I. Take I hour before or 2 hoorsafi:er antacids.
2. The incidenceofEPS ishigh.
3. It is therapeutic if ordered on a pm basis.
4. Haldol iscontraindiCllted in Parkinson's disease, seiZllre
disorders, alcoholism, and S<'vere mental depression.
5.
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~11
OI\l!lsf(W~holol'S
217
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well. Today the nurse notices that the patient appears more
anxious and Is demonstrating increased paranoia. What is
the nurse's initial action? What is the potential problem?
What patient teKhing is important?
EXPlORE
~------,
MyttlrsiI1g~ Is ywr one $IOj) 'Of CWIIine d1aptff review mater1als aI'ld
tt'SWrCfi. Prepare ,~ 5iJC(;6S5 with additional trux"'-5IyIe ~
DRUGS AT A GLANCE
LEARNING OUTCOMES
OPIOIDANALGESICS {IIIltllD
OpioidAgonists f'Jt}fll/
OpioidAntagonists
pil9tl.'J
(X1IJtm
(X1IJt m
" aspirin (o(eryls4l1cy/1c ocl4 ASA) patIf l j(J
Ibuprofen and Reklred Cfugs (IIlJt 118
COX-1/nhlblrol'5 pagt m
ErgotAlkaloids
Triptans
n 234
KEY TERMS
AOfibrrs
(X1IJt l}/j
{IIIlt 111
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migrain~ pi1tjI' i 1O
nocic:eptor pYJe m
opiatt paqt m
opioid {XIgt;;o
patient(ontrolled analgesia (PCA)
substance P pYJe no
tension htadarne {!QIJt i 10
{!QIJt ili
At a simplistic level, pain may be viewed as II defen4!! mechanism that helps us t o .woid potentially o;Wn.a.glng $Ituations
oids have the potential for dependence and can ,ause . ignificant drowsiness. To assist patients in obtaining:wcquate pain
relief, nonpharmacologic techniques may be used :l.lone or as
an adjunct to pharmacotherapy. When used ,oncurrently
with medications, nonpharmaoologic techniques ma-( :l.UOW
for lower doses and po:IIiibly fewer drug-related advn-5e effects.Some techniques used for reducing pain :l.re as follows:
Acupuncture
Biofeedback therapy
of this
e~enc:e. Anxiety, fatigue, aocl de~$S1oo can increa se the perception of paln;posltlve ,,"ltudes lind support
r.hssage
M~tation or prayer
treat their discomfort. There 11ft many options for pain as-
Chiropractic manipulation
OUI'Ct
2t 9
Hypnosis
PHARMFACT5
Pain
Pain il a (ammon l)'fIlptom, rule<ttd by the following statistics:
E",ry)ON' in Amm<.,.ppltllliJllilld'l' 16 million ~pk: ocp<:rio:JI(~ (hroni<
~rthritic:~in.
ilia!! than 11 million ,l(lult! 11m 1!pOrttd low b.Kk pain, while 19 million
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~.-
I;;
22 0
Unlll
"t
Sub5tanoe P
Receplor fo,
Receplor fo,
ot norepioophrine
lse''''orOn.norBpinephme
","u""," (corning
down from the b,ain)
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,"0
lrensmission
-"'F................. &ndings
(nociceptor)
OPIOID ANALGESICS
By definition, il nalgfsia are medications used to relieve pain.
The two basic cate-gories of analgesics are the opioids and
the nonopioids. An opioid analgesic is a natural or synthetic
morphine-like substance responsible for reducing moderate
to severe pain. Opioids are narcotic substances, meaning that
they produce numbness or stupor-like symptoms.
opiate.
IlYplflll
agonis1
anla.gonsl
Morphine
Pent azocine
COOO~
8utotphelnol
NalOllone
clln f<1C11J11ors
Mu: Analges",
DIIcrHsII<I GI motil;ty
Respiratory depression
Sedation
Physical depeo<loonce
T Kappa:
Analges",
DllcrM.5ll<l GI mo1il;ty
Sedation
.. Flgur!
most clinically useful classification method is by effectiveness, which places opiates into categories of strong or moder~ 1e ~c1ivity.
Opiates produce many important effects other than analgesia . They are t'ffectivt' at suppressing the cough reflex and
at slowing the motility of the GI tract for cases of severe diarrhea. M powerful CNS depressants, opioids can cause sedation, which may either be therapeutic or dett'rmined a
side effect, depending on the patient's disease state. Some
patients experience euphoria and intense relaxation, which
are reasons why opiates are sometimes abused. There are
many adverse effects, including respiratory depression, sedation, nausea, and vomiting.
All of the narcotic analgesics have the potential to cause
physical and psychologic dependence, as discussed in
chapter 1100. Over the years, health care providers and
nurses haw hesitated to administer tht' proper amount of
opioid analgesics for fear of causing patient dependence or
of producing serious adverse effects such as sedation or respiratory depression. Because of this tendency, some patients
have not received complete pain relief.
Narcotic opioid agonists bind to opioid receptors and produce multiple responses throughout the body. Morphine is
the prototype drug used to treat severe pain. It is considered
the standard by which the effectiveness of other opioids are
compared.
22 1
PurQ opioid
Pureopioid
Opioid Agonists
TABLE 18.1
Response
Kappa Receptor
Analge5i.J
.'
.'
Dtumfll Gl motiity
.'
.'
Euphori'
.'
~wl~
.'
iIt!pimory dtpmsion
.'
S!da~on
.'
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.'
222
Unlll Thi'Ne<vDI"Sy'tem
Drug
Adverse Effects
PO;I--4I111j~~4--i.hpm
drrlWlinm, dilziflm
Prurim,.cmsripio/l._,~olioQ.
~ramorph,OIhet!)
I:. -.
PO;IS--i.Olllljrjd
j,
>
OPIOIO ANTAGONIST'S
"
t
m~kg
HtNtOioxidty
dtzocillf (Oalgan)
1M;5 ~10mg(UIUiIIy
-c-cc--c-'--'-""'
--c--
lmMlinm,~ 1ig/rfOO!dtftlru,
euphori~, MU5lO, (IIImmy Iii", lweQ~1Ii
~Dbdomill<1l PQ~ wrnIipotion
lOmg)f'II'I)' Hh
lldicr indKite romroon advmt tffMs; lIII1flIiliDg. indKitts strious adm~ tlhru.
\'/hen used according to accepted medical practice, patients can, and indeed should, receive the pain relief they
need without fear of addiction or adverse effects. One
method available is patient(ontrolled analgesia (PeA). In this instance, patients are allowed to self-medicate with opiate
medication by the pressing of a button. Safe levels of scheduled pain medication are delivered with an infusion pwnp.
In the pha rmaoologic management of pain, it is oommon
practice to oombine opioids and nonnarootic analgesics into
a single tablet or capsule. The two dasses of analgesics work
synergistically to relieV\' pain, and dose of the opioid atn be
kept small to avoid dependence and narootic-related side ef-
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IlIaplfl tl
Opioid Antagonists
Opioid antagonists are substances that prevent the effects of
opioid agonists. Many druJ!;S are considered competitive antagonists because they compete with opioids for access to
the opioid receptor.
223
PHARMACOKINETlCS
Onset: liss than 60 m'n
PNk: 60 min PO: 2O-tiO min fl'(ully; so-9O min subcutaneously;
10-1 min 1M; 20 min IV
Halflife: 2-3 h
Duration: Up to 7 h
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ADVERSE EFFECTS
Morphill' may (iUS~ ~phoria (ll'IlifSVl~~ dtpression, and anxiety), halb:ioatio n~ OlUIti, con stipation,diuioeu, aocl .J n itching sen >ation.1lYfrdosf m y Il'suit in itVtfI' mpiatory depression or wdia( alll'll ToieriOO' dtYmps to the
SfdatiYf, naulti-producing. and fIJphoric ffItcts of tilt thIcj. Cross-toleran:t ilso
devrIops lll'iwffn morphilr and other opioids IlKh is heroin, mtthidort, aocl
meperi:lilt. Physiul aocl psychologic deptndmtr devrloJn wlltn high dosfi aIl'
taken fur prolongtd pffloih.
Contraindi utions: Morphine may inten ~fy or misk the pain of gallblacldtr disN~, dJf to biliary tract spasms. Morphinf should iM tit <lvoided in um of
acute or ItYfll' uthm., Gl obstnKtion,.ocI seYl'Il' hepatic or renal im pailllltfll
INTERACTIONS
DrurOIlJ!l: Morphint interac~ with WIl'I"iII m.gs. for txamplt, <llOOIIfI1t Uf of
(~dft:~n.llKhaiakOOol,othl'l opoids.lJI'IIfI"aI~lfdali'lfs.in:l
Unknown
Herba ~Food: \'OOimIH!, kiwa kiwa,vaIHiao, and St. .Iolm i wort may potentiatt tw
~ Ii lIHI~nt.
Treatment of O"ferdme: IV .ldministruion of nalolOOI' is the spe<iIic trratment Other IINtments indud~ iawated charroa~ a lixauY!', aocl a (ounteractiog narcotic antigonist.Multipifdoses may be ntfded
lit fer I!J M)MmlrrqK!/ for Q NurslfIIJ Pnxm form!pt(1k ro rIr/<i dr!!g.
I
;
224
Unltl
Thl'NetvO'"S)/lt'''''
Assessment
orc
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Explain the rltionale behiod the pain r,tiog suit (i.e., it allows consist.ncy
among ,II providers).
Encourlljf the p,tient, Ilmily,olUlI'9il'tr to LIIt~itionl~
nonphannKoiogi( p,in rtlitf ttdlniquf'!, e.g.,dismaion with ttltvision or
music. bi<krubs,guided imaljfr)'.
Impleme ntatio n
Interve nti o ns and (Rati o nales)
Minimizing ad'ftrlf rifKts:
o ContinU!' to monitor vital ~igm,r~ially respirnionland pu~OJ[irnetl)' is
ordrred, poltoperativ~1y and in patienn with arut~ pain.For terminal WKtr
pain, obtain imtrunion I from thr onc:oiogist or hospi~ providtr on any dOl~
I!"Itrictionl. (Respiratol)' tieprrllion is thr mOlt (OOlmon with thr first do!l'
of an opioid and whengr..eo in tilt pre~~ of othrr (NS deprrwnb, e.g.,
postoperatiY!'1y when thr pa~m may still ~ ~lprMnc:ing tfftru of
geo~1<I1 aOI'lthtIia. Cou nt rrspiratiom More giving the opioid drug and
(ontlo(\ the plOl'ider bef~ giving if the I!"Ipirationl are bdow 12 bft'athl
per minute inth~ , duk pa~n~ or 011 ordtft'd in th~ (hild. ContinU!' to alll'li
thr respiratory "t~ tvrl)' 15 to 30 minutes for the first 4 hours. For terminal
tall(('I pain, the drug may not ~ withheld regard~11 oftht I!"Ipiratory 1<I\e,
dtprndtm on thr proYider.)
o Ttath tht jHltil'nt to inau!l' fluids to II prrday and to iro:lUs~ tht iotakr
of dil'til)' fibl'lSuc:h is fruit, l'l'9'Ia~,and whoII' g~ins.
InstllJ{tth~ patil'm to report!l'l'l'II' {onstipation to thr hNith tart
providtrfor additional idvkt on 1a1iltiY!'l or stool SOftfners.
Monitor for itthing or {00l pia inu of it(hing. (Opioids m~y UUII' histamilll'
relm~ and it{hing or a II'fIS.Jtion of itthing.ln s~vell'taIl'I,antihistamilll'S
may ~ rrquift'd.kml br it{hing as an 9pKtrd sideeffett Y!'I>US signs
and lymptOnu of tllll' alltrqy/.naph~aJis:(hafl(jrs in vi,,1 sig~ tsptdilly
hypoten!ion and tI{hyra rdia, d)'lplII'a, or unica ria J
o [lI(ourage thr patient to IIIOYI' about in btrI and to start ~arly ambulation
as soon ilallo~d postoperatively.klist to i nolTllill voiding position if
unable to usr bathroom or IOmm~.
InstllJ{t th~ patitm to immediat~1y report an inability to void, ill(lUsing
bladder PII'SSUIt',or p.in.
o Thr parii'm should ~ able to lIatt thr It'alon for thr drug,appropriate
doII'and sdlrduliog,and what ~Y!'I!I' efftru to obItIV!' for and whrn to
rt portthem.
(Conr/nu~d)
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22 6
[valuall' effeuivtotSl of drug therapy II)' confirming that ~tient goa Is and 6 pt(\ed outcome haVl' been roo (SI'!' "Planniog1.
SH TQbIf' tlJ.lflU lill ~dfl!lp rcwhidHIrI'lt rNniIIq~clilm gpply.
18.6 Pharmacotherapy
.... Prototype Dr ug
Therapeutic (lass:
may be abused for its psychoactive effects; however, morphine, meperidine, and heroin are preferred beOluseoftheir
potency. Although heroin is currently available as a legal
analgesic in manyoountries, it is deemed too dangerous for
therapeutic use by the FDA and is a major drug of abuse.
Naloxone (Narcan)
Pharmacologic (lass:
~ioid
receptor antagonist
ADVERSE EFFECTS
PHARMACOK1NET1CS
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INTERACTIONS
I)ug- l)ug: 1lru9 inteOOionl ildlHlf a It'VN of thf aoaIgrsic: .lfem of opioid
agonists iIOd mind..,m.: O:ugs.
IlIoplflll
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227
NONOPIOID ANALGESICS
The nonopioid analgesics include NSAIDs, acetaminophen,
and a few centrally acting drugs. The role of the NSAIDs in
the treatment of inflammation and fever is discussed more
thoroughly in chapter 3J01C> . Therefore, there is only brief
mention here. Table 18.3 highlights the more common
nonopioid analgesics.
Nonsteroidal Anti-Inflammatory
Drug'lNIAID'1
The NSAIDs act by inhibiting pain mediators at the nociceptor lew!. When tissue is damaged, chemical mediators
are released locally, including histamine, potassium ion, hydrogen ion, bradykinin, and prostaglandins. Bradykinin is
associated with the sensory impulse of pain. Prostaglandins
can induce pain through the formation of free radicals.
22 8
TABLE 18. 3
Dru,
Nonopioid Analgesics
RoulI' and Adult Dose (max dose where Indicated)
Adver~
Effects
PO:(3)'-870 mg
wll.JLltt (llisakid)
{2.'-' mL)Mry 4 h
di'hllilal (Doload)
t\oOOIi( (lodint)
PO;lOO mg tid-ljd
i"IdoIntthHio (lndodo)
ketoprofffi (Aaron.Orudi,)
IOI'f~mic:add(PtoIItI)
IOI'loxic:.Jm(Mobic:)
nalPurrlttont (Rdaltn)
naproRll !OdiU1l
(AIel'!', Anaprox,OI~)
OliIpro.zin (Ilaypro)
piroxkam (ffldtntI
ruindH (Cjnorin
tolmttil (ToIKtinJ
crIroIxib (~I
CaUI"OUI Ulot
ACETAMINOPHEN
Q
dut to fDA
rrnew
oraDdryinQIaJhoiCJ
doridilt (Citapr~
trarnadoi (UlUim)
AnaphyOOkrtlion
~Qrktr,dizzi~
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229
",
",
pain and
'nlt B mma~on
Selectiw
COX-2 inhibito
o Celecoxib
Non_ lectiw
COX inhibitor.
o Aspirin
olbuprolon
Free"""""
endings
(nociceptor)
'.0
transmission
L_" .,
Tissued"""'98
"'.0
to increase
body te<rpe.llture
and cydooX}'genasetype 2 (COX-2).Aspirin and ibuprofenrelated drugs inhibit both COX-I and COX-2. Thus,
COX inhibition is the basis of NSAID therapy. Because the
COX-2 enzyme is more spedfil; for the synthesis of inflammatory prostaglandins, the selective COX-2 inhibitors provide more specific and peripheral pain relief. Celecoxib
(Celebre.~) is the representative COX-2 inhibitor. Other
COX-2 inhibitors are available outside of the United States.
,. Figure 18.3 illustrates the mechanism of pain transmission at the nociceptor level.
Acetaminophen
Acetaminophen is featured as a prototype antipyretic on
page 472 in chapter 33010. Acetaminophen reduces fever
by direct action at the level of the hypothalamus and
causes dilation of peripheral blood vessels enabling
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sweating and dissipation of heat. It is the primary alternative to NSAIDs when patients cannot take aspirin or
ibuprofen. Acetaminophen does not produce GI bleeding
or ulcers, nor does it exhibit cardiotoxicity. Aspirin and
acetaminophen have similar efficacies in relieving pain
and reducing fever.
230
Un'll Thi'Ne<vol"Sy'tem
Asp,nn (Acetylsal'cyl,cAc,d,ASAJ
ADVERSE EFFECTS
Aspirin inhibits pronaglaooin synthtsis inOlv~d in the pro<~ Ie of ~ in and inflammation and protium mild to rnocIfrite reliefof fewor. k has limit~d elfects
on p~iph~al blood 1'ffi~Is.utusing nsooiLllioo aoo lWt'ating.Aspirin ha, signmnt intXoagulant ictiYity,lOO this proptrty is rtSporIsibll' for its ability to
rroUCf tilt risk of monalil)' following Ml.iloo to It'du th~ incidelUe olnrol~.
Aspirin has also ~n foundto rroUCt th~ rilkof (olorfaal utlK~,ahhough the
m~thanism bt' which it alforos this prot~ ~ffKl is unknown.
ADMINISTRATION ALERTS
INTERACTIONS
I)ug-l)ug: OOrurreflt l1li' of phfnobartitaI, anOOdl, and 9WKottioim rruy
demai.! illpiin"s etIKt; . .l6pirin may potMWIf thf iKIion of oral h)1lOl#fmic
O:ugs. Ule(/; of tl>AlOi,lI"iroslU d~ such as prrbfnKid, btta bIockm,
SJirordaamt,and IUIa Ikugs may bf Iif<mIfd whfn rombitIN wi hillpiril.
PHARMACOKINETICS
()jset: 1 h
Peak: 2--4h
Half~ift: 15- 20 min (aspirin);2- ] h Iwlicylateat low dolf); molt' than
20 h (salicyl.att ill high dose)
Duration: 2( h
I
1!,
"
Headaches are some of the most oommon complaints of patients. Living with headaches can interfere with ADLs, thus
causing grea l di.tr.,. . The pain and inability to focuo and
concentrate result in work-related absences and difficulties
caring for home and family. \'/hen the headaches are persistent, or occur as migTllines, drug therapy is warranted.
IWrbaVFoo:l: Fnerf~, g.B. gill9fl,and ginkgo may i1aml' thf risk of blttding.
T~tment 01Overdose: TrNllllfllt may inWd!- an~of tlltlollowing:artivatfd
Challi~ gastric lavaqr, wau'',or drug theraPl' for Dl'!'rdolt symptorm wch as
diuines~ drowsines,abdominal ~in.or Ifilult's.
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PHARMFACTS
Assess ment
F'HI IAcuteorOwonid
Wr<lpMK df~.
intefa<tions.
Obtain wstiM vitll signsind Might
hiluatt appop riltf bboroJlOl)' findiJIgI (f.g., CBC,(OigUIation ~nd!,
bleeding tirM, hf~tic III rm.lfunction slm).
AMls tht pilimt's abllitylo r~(fift imd UOOU'lt.lnd etrunion.lndudI'
W bmil)' .ndc.tJf9i~ as needed.
lssHs mrnt thID ' ghout .ckninisIJltion:
Implementation
Interve ntions and (Rationa les)
Il\SllII(t the p,nitnl on tht Iftd to Iftum prriodiully for lab work if on the
drugs long tmII.
ltad! thf ",tirnlto abstiin from alcohol whit taking acflilminophtn.Men
who consu~lIKRthan twoakoholic bnmges prf &y Of womrn who
(onsumr JllCRwn Ont akoholic ~ prr &y should mm.uh tbN
.....Ith "' r~ pMidrr btf..~ tHing .<rt.minophm.
---'---
{Conrlnued}
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232
Unlll TheNe<vol"Sy'lem
Monitor uri III' output .J nd rt'na IfulKtion studiel ptriodically. (NSId Os ,nd
salicylate, may lit rt'nal toxic: and j)atienllon long-term or high.oose
tOOap)' should monitor urineOUlput and ha\'e ptriodil: rt'llal fuoction
studits.)
Tilf ~tien~ family,orcalt9~r should ill' abit to ltate llll' INIOn for IIII'
drug; l ppropriOltdo.. and Khedulir.g; whit Idvt"" d'km tooln<rw for
and when to report;and theanticip'led itngth of mMic<ltion theraII)'.
~pIy.
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~Pl
Hl
Adverw Effects
ERGOT ALKALOIOS
dilydlOffgOlalrine m~tt (O.HHS,
MigI,nal)
...-
TRIPTANS
aknouiptan (AIM}
A.!IIieiIiD,tingli"9-wmlll}lffllI1lioo.~
elMripun (Rtlpaxl
froutriptan(flM)
nar"riptln (""'~I
rilatriptan lM.iult)
o sumatrlptan (mitra)
IOImitriptan (Zomil!l
verli90
ANTISEIZURE DRUGS
topiram.tt llopimax)
Um~ilG
Ilm!: !!lil!lM~~l2D
BETAADRENERGIC BlOCKERS
.tenolol (Tenormln) lsee pi9I! 347 fOfl~
PtoIotypeDrugbo:w: OC
metoprolol(~~)
BmndmNl!!I.o!iatM: Itrmati!il.mou!omnn
II Kllba!!!: iritation rash ~iIll!!2!:!; QI!!W;!m!
~mololIBlotmn)
aNP!W!aJ~ SIM!I!-Jo!rnm
Syndrprm
nlmodplfH! (Nimolop)
MI ,w b!oct
~Da!p!0Jki!y
"'dIl!ion.d'tIwmts~orrhoMQti(ltyportmion.blurred
mioo.Jghl mydriaJiJ,ttymoufll,urifIQrytrrf~
(omtiporioo
prot~ylill (V"l"Iactil)
am~ripty~ne hydioo:tjoridf
[Eiavi)
MI
a!!l!!l~~,)!\ ~
mnoomosn
MISCELLANEOUS ORUGS
meth)"WflJiIIt ($inStIl)
riboliavillYitamin B,)
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234
Until
Th~
/lle<vOI" Sy'tem
Sumatnptan (Imltrex)
ADVERSE EFFECTS
ADMINtSTRATlON ALERTS
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INTERACTIONS
I)ug-l)ug: Sum.!tripUn ReroKll wth ~ d~FII" fIi~,jn ilKlNlfd
ffl'fU may (]I" WMo t.en with moooamiM' OIida1t inhibitoo IMAOfs) and
~.".serctooin rftlpli~inhibitol5ISSR1.1.Furthfr ~ IOlII ouur
Treatment of O"RrdO.f: Tl"!atment IIIiIY ilKludt dllHj theraPl' for the following
.ymptom.: weaimtu, loKk of (oordination, watel)' r)'f! oInd mooth, treman,
leizurel, or bl"Nthing probltm .
Rnfor III MytmIfIgKI (or a tmIniJ /'rIxts5 fooIlIpK/It: 10 1M <tI!q.
c..,1II'1'
Oru!Jslorthec.ontfolofP~ln
1]5
A.uenmerrt
lIawoIin~ ISS6I111~nt prior to administr. ion:
UndeI5t1nd 1bt ~ason tilt cWg ~ ~n pm<ribtd in ordeIlO auns fof
therapMK ~fIects.
Obtain i {ompkot~ health histOf} inWcling unliovHaA.r~nrurologK,
htpllic..or ~ d~~;plf1ll'oall(';or b~~t-fwling.OIK.tin it drug
history iIIdud ing illtrgit1. ontnt presaiption and ore drugs, h~rbal
IRP'Iratioo!, {i~n~,nicotJn.t.,and ilmbollM.BeaRrt 10 poI~bIe drug
NI,I15in9 Diagno5u
Anat Pain
intfftil't fiNllh Mlinltl'oaOO! (rtlattd 10 mbilit, 10 mI"'9t ~tMtiH of
eliiii' liYingwi1hdvonK~inl
~tiI'tCopMlg{rtLiltdllldwolrK~in)
DefKitntK~(drugthtr.py)
~wssfor~theIiPftllit:d'k<n(f.g.,headachep;lin is~~
or
absent).
ConlinUl' monitoringltftl of{OOKiou\nm.nd nrurobj:: symptoms (r..g.,
num~lor~ing).
....,.
lNdr the p.ltimnhat Plin rtWf; latht r than mmly {O~ is thegoal of
EnlDUrlgt tht patitm to tlktthe drug bdIre a hfarbc:he bfc~ ~
and ronsisturtly ~ ordroml.
Explain th~ I1tionilt bthind t!rr pain raling Kilt (i.t.,iulO'M (onsistrfllJ
iIIIOII(I all p!O"fidtn).
Inmurlgt tht patitm to US!' additional, nonphannarologir: pain rtlitf
itdDqutS, t. g., quit!, dinzMl, tool room.
(Conrlnued)
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23 6
Unltl
TheNe!\rouSSyslflTl
_ _ _+C
" C'C"C"::.
t and family Eduuotion
Mini..izill9ldftnt fft'ts:
Moni!l:lr the blood pl!SSIIIt IIld fIU~ ~IJy ~u,. in palifftUIt
ris.\: for UtWgrmtd c.tdiomOJwltlisu~.urdio'lua.Ursta1us should be
monito~ ~nll,folowing the fiBI clost giIom. {lriplillli (,)USf
mO(Olrnriaion.POllmtllOpiIIIoIIWOIIIfl!,mtn O\If/.o, vnoio:tn,.nd
people willi othe! known CAD risk (aclM II1I'I be II the ~ltSI risl)
~ of"th\llldefd.lp qwlity
lnstnxt tht pI~m 11:1 Ifpolt .nydltst pBI. tightnflS, III pulslting .ctivity
1M iI st\'el'f III aHlunUts IoIIowiog dlll!l dosq.
IiIjn.l~iKhI-miaJ
""~
TtoKh tht palirfll: ID uu the mtdK.ttion brloR the pain br<0II"IfS SrYm or
1\ tht fiBISymjl10rns of. migriint ~ possille.
Tt.achlht patinJf tIM< proptI' Idrninillration of lIIiKuuntOlll mtdication,
Ming tht plbtn( or urtgWtllf!Um-OrIllOlllUiltr t~ ItChniJlf.(Pain or
I!dness lllhe in;t<tion S~t is CDmmOll but II!.UIlly disaPIIUII within in
how alttr 1M clost iI takm)
lnstnxt the pltitm that an ' ppIOfIna!r inuan.asal dost ii_splay iota
ONE nostril unltsloth_ist ordt~ by the hNlth c.1t p!Oidtr.
&aIIr.tt t ffKtitnelof drug thmpy iI1 <onfirm ill9 thlt pltifftlgGilll iItId Upt<tfdOlll(DmM hal\! been mtt {Sft"Planning1.
5ft iI/IIt 18.4 rnIt1'tipfQns'for dulfdfllJl II rmidr rhMllfllilll;ffIkInf QPJIIf.
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o..plfltl Onq;iont...ConuoIofp.ln
'\
237
Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide 3 succinct summary of the important points from the corresponding numbered section
within the chapter. If 3nyofthese points are not clea r, refer to the numbered section within the chapter for review.
18.1
18.2
18.3
18.4
18.5
Opioids are the drugs of choice for severe pain. They also
haw other important therapeutic effects including
dampening of thecough reflex and slowing of the motilityofthe Gl tract.
18.6
18.9
Headaches are classified as tension headaches or migraines. Migraines maybe preceded by auras, and symptoms include nausea and 'omiting.
The nurse recognizes that opioid analgesics exert their action by interacting with a variety of opioid receptors.
Drugs such as morphine act by:
t. activating kappa and blocking mu receptors.
2. inhibiting mu and kappa rq>tor .
3. activating mu and kappa receptors.
4. blocking sigma and delta receptors.
The nurse administers morphine sulfate 4 mg IV to a patient for trrutment of severe pain. Which of the following
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II
Nursing interventions for a patient receiving opioid analgesics over an extended period should include:
t. referring the p.11ient toa drug treatment center.
2. encouraging increased Iluids and fiber in the diet.
3. monitoring for GI bleeding.
4. teaching the patient to..,lf-......,.. blood PreMUfe.
1:1
The most appropriate method to ensure adequate pain relief in the immediate postoperative period from an opioid
drug would be to:
L give the drug only when the family met1lbers report thai
the patient isoomplaining of pain.
2. give the drug {'I.ery time the patit'nt complains of aalle
pain.
3. give the drug as oonsistently as possible for the first 24 to
48 hours..
4. give the drug only when the nurse observes signs and
symptoms ofpain.
actions?
1. A 64-year-old patient has had a long_sta nding history of
EXPLORE
~--------,
mOlJfO!'S.
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LEARNING OUTCOMES
DRUGS AT A GLANCE
lOCAL ANESTHETICS
Amides (IIt141
~UO
&lses
Itlkltlll!Uqulds (JfJIJt147
ho/orhan. (F/uoIIIDMJ , . ut
Intra'ltnousAgtnts pogtUJ
lIarbltumtt and BorbHurot1ct ~u
plllltlSI
Q rh~nrol{PmfothaQ pogtlSl
0p/0ltJ$ ,..151
9fnzodlcwptlfS ptIIJtXI
Opioids
ptIIJt1S1
ptJ9t lS1
Hewomu!(UlarBlodling Agents
!ifl41
nllrousO/(~ {JIig/141
ADJUHClSTOANESTHESIA
ptJIJ/15]
KEY TERMS
amide (II19t241
balanced anethelia
(JI19t 246
nil!!' fJIJIIt)j]
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24 0
Unlll
Th~
/lle<vOI" System
Local Anesthetics
LOCAL ANESTHESIA
Local anesthetics are drugs that produce a rapid loss of sensation to a limited part of the body. They produce their therapeutic effect by blocking the entry of sodiwn ions into
neurons.
(h)
Infi~ra/"",
- =
(d) Spinal
(e) EpiWral
,. Figure 111.1 Techniques tor applying local anenhMla:la) toplcal;lb) Inilltrallon;(c) nerve block;ld) splnal;and Ie) epidural
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Chop! 19
241
Formulatlon/M{'1:hod
C){'5C~ptlon
'"
PHARMACOTHERAPY ILLUSTRATED
19.1 Mechanism of Action ofLocal Anesthetics
,"rye c:onduction;. Il0l"I11III.
Sodium channllls are open, allc.ing Na+ to ent ... the neuron.
~------~--~------,
N_
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Unlll TheNe<vol"Sy'tem
24 2
PHARMFACTS
Mo~tlun
, 9.3 Classification
of Local Anesthetics
Local anesthetia are classified by their chemical structures;
the two major classes are estfrs and amidrs (Table 19.2). A
small nwnber of miscellaneous agents are neither esters nor
amides. As illustrated in .. Figure 19.2, the terms ester and
amide refer to types of chemical linkages fOWld wi thin the
anesthetic molecules.
Cocaine was the ftrst local anesthetic widely used for medical procedures. Cocaine is a natural ester, fOWld in the leaves
of the plant Erythroxylol1 coca,native to the Andes Mountains
of Peru. A5 late as the IS80s, cocaine was routinely used for
eye surgery, nerve blocks, and spinal anesthesia. Although still
available for local anesthesia, cocaine is a Schedule II drug and
rarely used thel1lpeuticaUyin the United States. Theabuse potential of cocaine is discussed in chapter 1100 .
Another ester, procaine (Novocain ), was the drug of choice
for dental procedures from the mid-l900s Wltil the 19605,
lUltil the development of the anlideanesthetics led to a significant decline in the use of the drug. Ont' ester, benzocaine
(Solarcaine, others) is used as a topical OTC agent for treating a large number of painful conditions, includingsunbum,
insect bites, hemorrhoids, sore throat, and minor wounds.
. '"
Chemical Classification
Orug
. ooil. (!.optodont)
bupiv.uilll' (Ma"YiIll')
dilHKiilll' (NuptrGJiIlf, NlpfItIi nal)
Q
lidoCiIiIt (Xylocaile)
priocaile (CitantSlj
ropWac.Jilll' (Naropio)
f-[slfrs
(J(5ikpmsim
proGIilll' (tfu.oocaill
ttu~ain~ (Ponioailll')
MiKtilintOUs ilgftlil
11~1ia inli<att
dydonilll' (Dydoritl
pramoxilll' (Tronotllalll'l
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Rt!i!:at!l!lomrd!Harrm
CNptor l'
"eo
243
Example
o
,,~
R- C - O -A
"
Procaine
o
Amidoo
"
R- NH- C - R
Lidocaine
,.. Figure 19.2 Chemical struc!uresof ester and amide local anesthetics
sion. Cardiovascular effects. including hypotension and drsrhythmias, are possible. Patients with a history of
cardiovascular disease are often given forms of local anesthetics that contain no epinephrine to reduce the potential
I Lidocaine (Xylocame)
ADVERSE EFFECTS
ADMINISTRATION ALERTS
Solutions of lidouilM! (onlilinillC) presmatiYft or tpintphrifll' are intrnded for 1001 afll'Stlrsi.l only, ind mun neY!'r ~giYrn pamltefaUy for
dysrftythmias.
Do nOi apply topitalliiouinr to IIIrgr ~in areas or to brokrn or abraded
ilreas, bKaIM !oignifiunt absorption IIIiI)' cur. Do nOi allow it to (ome in
ClIn!Xl with the r)'H.
For spinal or epidural bIoc:k, u~ only preparations !pr(ifK.l II)' 1II~1rd for IV
=.
PregninquttgoryB
PHARMACOKINETICS
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INTERACTIONS
--
I..ibTi5ls: IncJN\fd(PK
Herba~Food: Unknown
Treatmrnt of O"ft'rdosr: Emttgtnq mt<lital antmian is I"ftded beciIIM of
the miny ilSociillrd 5Ubslilmil't' s)'lllptoms IIKh as blNlhillC) dif'irulty,
swtllirg of tht lip~ tlirst pain, irrrlJ.llar heart ~iI~ niIMi, yomitiog, tllmon,
and sHureac:liYity.
I,if
244
Unlll "TheNelvoo.Sy.tem
Assessment
Assfss~nt
Trach the ()a tient that tIlr UN m.y br numb for se~r.tl hoursaft.r the
pnxf<!UIl' is (ompletf<!.
T_h the p,>titnt that it is norm.1 thaI. !light PIl'.rul'l' ns.nion m.y Il' .... in
during ~nrsthesia (r.g.,.tnsation of"luggio( during suturing) but that no
()ain should ~ ~h.HaI'l' tIM< patient ,ifn tIlr he.kh ca~ proI'idu if IIIO~
than a .Iight pIl'SSUIl' <l'Osation or.ny ()ain is notic:td ruriog ,nmhesia.
Trach the ()atiem that it is normal to ~in 5010f ability to mO'ff limbs (e.g.,
alter tpidur.ll ' IIfItheiic) ,nd mOYl'lOent may Il'tum brlort thr abilil)o to led
thf IIIOYl'IOrm.
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Chop'.. t'
245
,.fieJ
uution the patient 001 10 tat,dww gum, or drink until the IIIOU1h
~nsation hasll'lU,ntd ifklcal (dental) ororaVthroatantlthesia has been
usodlf throot ane.tIl ..... Wtl u <I, a, sn. tilt gag rtfltx t:.c-for., .ating.
(loci I antltlll'tics all' effKti~ for up 10 3 hooll or mOIl'. Biting injuries to
oral mucous mt mbrantl may ocrurwhile lis= is numb.Aspi,ation of food
or liquids is possible um~ swallowing !m.Jtion and gag ,tilt. Il'lums.)
Instruct the patient 10 Il'frain from eating or drinking for 1 houror moll'
postanesthesii or umilstlllition has oom~ Il'lUmed 10 tilt oral cayity
orthroat
Instruct the patient to call 10, misun<r prio, 10 getting out of bed or
anempting 10 walk .Ione post- epwr. Iblock,. nd to avoid drNing or other
actjyitits Il'qui,ing physiul coordination (t.g., ll'9ional uppt, limb block)
umit the ,t-sidual tifem aftIII' drug all' known.
The pat;'nt .hould bt Iblt 10 ,!.Ito the " .. on for tilt drug, .nticipltod
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om
246
TABLE 19.3
'UO'
1
GENERAL ANESTHESIA
Gt'neral anesthesia is a loss of sensation throughout the en tire boo)" accompanied b), a loss of consciousness. Gt'neral
anesthetics are applied when it is necessary for patients to
remain still and without pain for a longer time than could
bt' achieved with local anesthetics.
19.4 Characteristics
of General Anesthesia
The goal of general anesthesia is to provide a rapid and complete loss of sensation. Signs of general anesthesia include
total analgesia and loss of consciousness, memory, and boo)'
movement. Although these signs are similar to those of
sleeping, general anesthesia and slet'p are not exactl), tht'
same. Gent'ral anesthet ics depress most nervous activity in
the brain, whereas sleeping depresses only vt'r)' specific areas. In fact, some brain activity actually increases during
sleep, as described in chapter 1400.
General anesthesia is rarel), achieved with a singlt' drug.
Instead, multiple medications are used to rapidly induct'
lUlconsciousness, cause muscle ft'laxation, and maintain
deep anesthesia. This approach, called balan~d anesthrsia, allows a lower dose of inhalation anesthetic, thus making tht'
procedure safer for the patient.
General anesthesia is a progressive process that occurs in
distinct phases. Tht' most efficacious medications can
quickly induce alt four stages, whereas others are able to in
duCt' onl)' stagt' I. Stage J is where most major surgery occurs; thus it is called surgical anrsthesia. \'lhen seeking surgical
anesthesia, it is desirable to progress through stage 2 as rapidl), as possible, as this stllge proouces distressing symptoms.
These stages are listed in Tablt' 19.3.
TABLE 19.4
Q n~rous oxide
Go.
General anesthetics are drugs that rapidly product' lUlconsciousness and total analgesia. These drugs are usually administered by tht' IV or inhalation roUles. To supplement
the effects of a gt'neral anesthetic, adjunct drugs are gi~n
before, during, and after surgery.
"""
"'"
General Anesthetics
\bIati~
liqtid
dtsfhrrant (Sup_)
rfIfturaot (E!brant)
M~dial dep!ession
Q halothane (Roothane)
isofhrrant (Fu~~J
meThoxyllurant (Pmthraot)
~rant (Ultantl
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~ Prototype Drug
Therap~ti c Class:
I Nitrous OXide
General anesthetic
ADVERSE EFFECTS
Whr n usrd in low to moderollt dolts, nitrou! OJide produc:es lew <I~ tfInn.At higlltr doles, p-atitnn tlh ibit Klint adYMr sign! 01 stq 2 antllhtsia
wc:h <I! anlitty, aUtrml'nt. and comb.niYrnrs~ lO'ftring tht inhaled dolt win
quickly rtVtlse thes~ 'Mise ~tftcts. As nilrous omr is ~xhaltd, tilt patitnt may
temporarily ha~ KImi' dilfkulty bft'athing at the md 01 a pnxrOJII'. NaUIN
and vomiting following the proredurr aft' moll' common with nitrous oxidlo
than with other inhalation ' lII'sthetiu.
Somt ~lII'ral alll'!thetic:s inlreqllerltly prodln li!'r d.Jma~. Nitrous oxidlo
has thr potential to lit abustd by Ulm (lOIIlttimrs medical personntl) who tnjoy thr rtlaRd,ltdat~ statt that tilt drug producrs.
Contraindi cations: Thi! dlll9 is cootraindiuttd in patitnn with an impolift'd
le!'IolcOO\Ciou!lII'!~htad injury, inability tocomp/)' with inllrucrion~decom
pr!"!!ion ~dlleS! (nitrogtn naltosis, <l ir r mboiism, air mnsport), undi.lgooltd
abdominoll p-ain or marktd disttmion, bowel obstruction, hypotension, Ylock,
chronk obstructi!' pulmonary diseol~, C)'anolis, or chell trauma with plll'llmothOiail.
ADMINISTRATION ALERT
Establi!h~n
aft'nttded.
PHARMACOKINETICS
Onset: 2- S min
Iflk: ll-suhan IOmin
Halllift: Variable
Duration: Patitnn II'mvtr lrom anesl~i.I rapidly alter nitrous oxide is
~utd.
----"'
INTERAalONS
Drug-Drug: Sympathomilllflirs 0100 ~inhilitln rna)'~1ol(erbalf
d)'llh)1hm.
_..
li bTl5Is: Unknown
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IV Ane,thetics
IV anesthetics are used either alone, for short procedures, or
in combination with inhalation anesthetics.
248
Unlll
The
/IIeIv"",, Sy'tem
Halothane (Fluorhane)
PHARMA COKINETICS
()tset: 2- 5 min
Peak: Les than 10 min; the minimum alvtolar (onmltration (MAC) is
0.1591i.MI( is rut<! in older adulK
Half~iM: Variablt
Duration: Halothane's du rilion of action is '/aria bit dot to iulipid solubility. Patifnu !Ol'tl" from .J nesthesii r~thtr rapid~ aft~r halothane is dis(ominuN lvariablt among diflerrm q groups; oldtr adults tJkt longer
to rfWItr).
ADVERSE EFFECTS
Halothane rnodtrately srnsitim tht hean IIIJKIt to epinephrine: thtft'fort'.
dysrhythmia! a~ a mncfm. This qnt Iowtrs blood pft'SSUrl' and the respil1ltion 11111'. k also _nol1lI'S rI'fI9 m~dianisms that normal~ kttp the (ont~ms
of tht stomilm from tnttrill9 tht kJ~. !!aUS! of potenrial iltpalOtoxicity, tht
UII' of halothane has dedined.
Malignant hypertht nnia is a rift' but pot{'fltiil~ fatal aciY!'BI' tffea triggertd t:,r all inhaloltion anesthetics. k caUll'\ mUlde rigidity and ~tft' trntpl'l"oItuft' Mation (up to 4l'C). This rilk is gft'atest whtn halothane is lISt<! with
IIKdnykholine.
H~ Iotha ne dilates the (f~bral '/a\QJlaturt and may, in (Main (onditions, in(INS~ intrauanial pR'"ISu~.
il@rbaVFoa:I: Untncwn
TrRtment of OmdoS!': No spKiIK
symptomatically.
ther~py
RtI\'r 1lI MyMIsIniJR {Ix Q MIsIniJ 1'roce\S FoM lpK/II( IIII1r1! <tug.
HOME
&
---~
COMMUNtTY CONStDERATtONS
--
--~-~----.-
19.6 Pharmacotherapy
with IV Anesthetics
Intravenous anesthetics, listed in Table 19.5, are important
supplements to general anesthesia. Although occasionally
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used alone, they are often administered with inhaled general anesthetics. Concurrent administration of IV and inhaled anesthetics allows the dose of the inhaled agent to be
reduced, thus lowering the potential for serious side effects. Furthermore, when IV and inhaled anesthetics are
combined, they provide greater analgesia and muscle relaxation than could be provided by the inhaled anesthetic
~lone. \\fhen IV ~ne.thetico are ~dmini.tered ~lone, they
are generally reserved for medical procedures that take less
than 15 minutes.
Drugs employed as IV anesthetics include barbiturates,
opioids, and benzodiazepines. Opioids offer the advantage
of supt'rior analgesia. Combining the opioid fentanyl (Sublimaze) with the antipsychotic agent droperidol (Inapsine)
produces a state known as neuroleptanalgesia. In this state, pa
tients are conscious, though insensitive to pain and Wloon nected with surrowtdings. The prernbred combination of
these two agents is marketed as Innovar. A similar oonscious,
dissociated state is produced with ketamine (Ketalar) .
249
Assessment
c.
o
,"
>
,,"'' '
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250
Unlll
Th~
/lle<vOI" Sy'tem
!1J((~III'~ il rafl'llnpolfllti.tllyfatal~f~tilndanyimilll'in
Providt i rationille for pain fl'iief pll'OpI'I"illivtly and elKou ril9t tilt
patient to requet pain medication a\ ablt. Assufl' the patien~ family,or
cartgmr that pain n~ds will befrequently monitOffd.
Teilch the patient dtep bfl'athing run:ises in the prroptratm period and
that t-arly mol'l'ment oflegs will lit flKouraged in the wiy postopet"aul'l'
period,unless othtrwill'ordtfl'd by the PlVlider.
uplain tilt full procedufl' ind r~uifl'd pollplIXedural UfI' to tilt patien~
family, or (afl'9i~~.Alert tht family or ufI'gil'l'f that visiting may lit
rt-nOOed during the immediate fl'(01'1'1~ period in order" to minimii'l'
Sl'MOI)' stimulation.
The pillifm shook! lit able to lIatt tht f1'asoo for drug(s),inticipated
II'nsations, ,nd ad,,~ efftru 10 obll'fl'l' for and wlltn to f1'port them.
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G@neraIAdverSf' Effects
Drug
~ lOmidal~
(Amidaltj
lJnjrJfl~ (ooMio'l.lIr/5IPQdi)m
prop<IoI (Dipril'~n)
Btnzodiul'pintl
dmpam(ValiLmJ
Ioraztpim (AlMn)
Car~!!(ular roUapg:.laryngosoasm
NaIJSffJ, GI dimJrooocn
M.J1k~ CNS depmsion
I reallifW (~talarj
MisctililltOUS
I Thiopental (Pentothaf)
PHARMACOKINETICS
30--60 ~
~k: 10- 30 min
Half-life: 12 min
Duration: 20-10 min
On~ :
ADVERSE EFFECTS
Lik~ otht r barbirurates. thio~t.J1 can product 5t'Yl'I~ repirnory depresion
when ultd in high doles. k is UIfd with caution in poatimll with cln:iiO'mcular
distill' beulIIl' of its ability 10 deprl'SS the m~ardium arod cause dysrhythmin. Patients may 6pe~1K1' tm~lgffi(f dtlirium postoptrativf~. This (!!M1
hallucin,lIion~ confusion, and tJ<iubility.
Contraindi Clitions:Thio~tal should not lit administefl'd to poatimts with hy~nsitiYity to baroiturat!'! or wi th eins unsuil! bllo for IV idministrarion. Variegatt porphyria or !rutl' intefmitt~t porphyria a~ mmraindications.ln t~
ca~, thiopl'mal or oihl'r barbitural!'S can ClIUse IH'I'II' c1tmyl'lination and CHS
lesions, whic:h may !tad to pain, 'ft!knts~and Iife..th~!tening paralysis.
INTERAalONS
DrurDrug: Thiopental inm!(!S with mooy 0!lIft' 00Jgs. For uilmplt, 1M with OIS
dtpressaIlll pot~tiate\ rllPr_tory arod OIS dtp"Mon. PhMotlia!iIt1 OOf!1f lilt
rM ofhypotemion.
li blets: Unknown
HtIba VFood:
Treat mf nt of ImrdOI~: Btuust tilt half~ifr of thiopental is vtl)' brid; Ut'trdose is ~asi~ managrd in tilt surgical suit~ by dilcontinuing tilt drug ind usisting Y!'nlilalion untilrepiritionl [ftum to normal.
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2S2
AltithoilWfgk
General A.d~
"""
EIfe<I~
~l1IOlIfl!.urWJ"rtftfNI
atropine
midwMn{\estd)
~,~/c"mfitttJ,~
d~II!WpIiIr)
hyportm.b.\ IIKhyrilrth
I.Jfmaoso.lsm
NNomUKWr~
Opioim
mivurium IMhoooo)
bn:Incho~1ITI
McOOtfosdai~M~hypo/fllliJfl
o JUinyIctIoIint (Mtint)
IltlOCurarine
dm lt.llt[HIII~1r;II:
ftrI.~ ~mCIII"1
im!!l
!!I!W<NSdnrnWn
Utmd1l5ilM,ttymouth
~!l!l~m!!OOM<KiI
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Chopt.. 19
253
Succrnylchoirne (Anectme)
PHARMACOKINETICS
OnS("\: O.s- 1 min 1V;1- 1 miniM
PNk: Unknown
Halflife: Unknown
Duration: 2- 3 min 1V; IO- 30min 1M
ADVERSE EFFECTS
Succinykholillt can caus~ complete paralysis of the diaphragm <l nd inten:OItal
mu~lH; thus, IIII'{hanK11 Vl'milation is n~(e\ary during wrgery. Bradycardia
and II'spiralory dtpll'SSion all' txpled <loMlSe eflfch.1f dole all' high. tilt
gangli.l all' affecttd, Llusing U(hycardia. hypotension. <I nd urinary II'ttmion.
P<IIitnn with {tnain gtntlKdtff(l\ may tilpMmc:t <I rapid onle! of tiltll'll\ely high ieY!'r with mu5dt rigidil)'--.l strious (ondition known as malignant hype"h~nnia.
Succinykholill!' should bt t mployed with caution in patitnn with fracture
or musdt Ipum~btcaU\eth~ initial musdt f<lIlKulationsm.ty caus~ additional
trauma. Nturomusrular bloc:kade may bt prolonged in palitml with trypokaltmia. hypocalct mia.or low plasma p~holintSteras~ ltvtls.
Contraindi {alions: Su{(inykholi lit should bt used with atll'lIII' (,JUlion inpatitnu with 1t'IM' bulTll or traum<l. nelJtomUI(IJlar disNsfS, or glaucoma. Succinylcholint is (onmindicated in palitnts with a fami~ history of malignant
hyptrthennia or {onditions of pulmonary. 1I'I\a1. (ardiO'm(utar. IIII'labolic. or
hepati( dysfulKlion.
INTERACTIONS
D"'!t"Drug: MdiOO ,bltulllllldo bIo<bdo wil lKtU"if "",rlnykboli.. ;'9;""
{ooum n!lywith dindarnycin.ami~ flnsnirle, ithUn, quiridi ...or
lidocai ...1lII' eIfl>ct of SlK<i1yk:hoIillt may tit ilaU\fd ij giwn (OOOI"ffItly with
phtnothialilltl.oxytoon.prmwirlf, taoi ... orthiaz.....iu.1lII' ~ of
'il.(~ . . ~ droNsfd Wgiwn with dazrpim.
If !hi! drug is gil'en (l)I)()JIIfII!ly with haiolJlant or ritrouI oDdf, an incrr.M:! risk
ofbOOycMda, dysrhyllnias,siMamst,apne.!,and maignant~ ~m
If !U(OOjkholi.. is 9ivPn {(.OOJffllily with Uo1Iiac 91y<Dsidt>1,!Mrf ~ incrr.M:! risk
of ~iac dysrhythmias.1f nartotics a~ giwn (OIl()JffI"jjy with '>lKtin)tholirlf, ihfII'
~inc~riskofIJild)U~and!iMatf&
LlbTfSls: Unknown
HOIbaVFood: Unkoown
lINIment ofOverd_: lINiment may involY!'drug thtr~ py forthefoliowing
symptotnl:WI'akness.l.t(k of rooldination. watery ~ and mouth, tmnors. and
s~irull'S. ProbIeml with bruthing requill' tmergtlK)' medital mtalUlI's.
I+tftt [0 M)Nu1l1frglJ/ for Q NullifJ9 I'Ioct1! focus lpt(1k [01Ir/s ~
KEY CONCEPTS
The numbered key concepts provide a succinct swnmary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
19.1 Regiona]]ossofsensation is achieved by administering lo cal anesthetics topically or through the infiltration. nerve
block. spinal, or epidural routes.
19.2 Local anesthetics act by blocking sodium channels in neu rons. Epinephrine is sometimes added to prolong the duration of anesthetic action.
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antianxiety agents. barbiturates, and neuromuscular bkxkers, are administered as adjuncts to 5Urgery.
The nurse should ass-ess the patient for which of the following side elfecl5lf succInylcholine (Antellne) Is used as
an adjWld to anesthesia? (Select aU that apply.)
I . Bradycardia
2. ~headache
J. Hypertension
4. Respiratory depression
5. Urin.1ry frequency
A [XItient is admitted to the postanesthesia recovery un it
(PACU) after receiving keumlne (Ketala r ) after his minor
orthopedic surgery. In the recovery period, the patient
should be:
I . frequently oriented to time, place, and penon.
2. kept in a bright environlllt'f1t so there is\ess drowsiness.
J. assessed IOrsensorydepriY3tion.
4. placed in 3 quit'!: place with low lights and away from
noisy ~tients or equlplllt'f1t.
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EXPLORE
~r!ingJll ~ ycMII'
rwJlues,
f'I ~.
~CLEX"'-tityl~ pradDI
Drugs for
Degenerative Diseases
of the Nervous System
DRUGS AT A GLANCE
LEARNING OUTCOMES
OopaminergicAgtnts (ill/t157
" Ievodopa (Larodopo) pilrJt lJ
Anticholintrgics
p:1IJt1S9
Q benmoplne (Cogenrln) ~ 16J
fflgt}64
fJII}t164
KEY TERMS
acrtylcholineteraSf (AchE) IllIJt 164
Alzheimer's disNS! (AD) ,..163
amyloid plaqun p<!'11'163
bradykinrsia (II1JtiS6
d~m~ntia ~ 163
hippoGlmpus pu;t 164
multiplrsderosis (MS) paqt166
corpusstriatum {X1;I151
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neurofibrillarytangl~ Jl!qt263
256
Th~
Until
/lle<vOI" Sy'tem
and
PARKINSON'SDISEASE
Parkinson's disease is a degenerative disorder of the CNS
caused by death of neurons that produce the brain neurotransmitter do pamine. It is the seoond most common degenerotive disease of the nervous system, affecting more
than 1.5 millio n Americans. Pharmacotherapy is often successful at reducing some of the distressing symptoms of this
disease.
PHARMFACTS
Degenerative Diseases
of the Central Nervous System
Men thn 1.5 million Am~riuln ha-;~ Partinloo's dis~ast.
Most patifnts with Parkinson's disNs~ U~ oIdtr than i9l' so.
Morr than SO% of Parkinson's patienll who hm diffirulty with voluntary
lIIO'Iement all' ~ngef than 60.
Morr men than women de-YeIop Parkinson's dMi~.
Morr than 4 million Ameriu ns haft Alzheimer's dM.m.
Alzheimer's di~.m mainly afftru patients older thin age 6S.
Of all parif,nIl w~h dmtentia,Wl'. to 11m ha~ Alzheimer's dise_.
Morr than 49,000 Ameritans die anrually of Alzh~imer's di~_.
OYef 2.5 million peopIeworidwide hi\\' mukiple sdew.
Morr than 400,000 AmerKaln hoM mukiple sderosis.
Morr women than men de-YeIop mukiple sderosis.
Multiple sclerosis is fil' times mOIl' pIl'Vilent in temperate climates than
in tropical dimatn.
D<><e.tptton
Aizhrilrler's dilNlt
Huntington's dIor~a
m."'"
Oemyrinatioo of IIN'OOS in the Wlual nervous systml (eNS), ll'Iiliilg in progrn~'Il' WNknm, Yisual disturbaoc:ts, mood akmtioos,
and '091itift driKits
Progr~sift 1011 ofdopalTi~
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,,~.
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257
mapler 17010 that antipsychotic dru gs act th rough ~ bl ockade of dopamine receptors. Treatment with certain antipsymotic drugs may induce parkinson ism -like sy mptom s, or
EJ>S, by interfering with the same neura.l p~lhw~y and funetiorn affected by Ihe lack of dop:!mine.
EPS may occur suddenly and become a media d emergency. Wi th aCUle EP5, pa tients' mu scles may spasm o r bewmt ~ locked up.~ Ftver and confusion are o ther signs and
symptoms of lhi s reaction. If amlt EPS occ urs in a health
care facility, short- term medical treatment can be provided
by administering parenteral diphenhydramine ( Benadryl).
If EPS is recognized oUlSide the health care se tt ing, the pa tient should immediately be taken to the emergency room ,
because untreated aCUle episodes o f EPS ca n be fatal .
Parkinsonism Drugs
Antiparkinsonism agents are given to r/.'S tore the ballnee of
dopamine and acetylcholine in specific regions of tht brain.
These drugs indude dop.aminergic drugs and anticholinergics (cholinergic blockers). Dopaminerg ic drugs art listed
in Table 20.2.
Oopaminerg/cs
These drugs either restore dopamine functio n o r stimulat t
dopamine receptors located within the brain. Recent t fforts
have focused on the use of dopamine agoni sts fo r th e initial
treatment of Parkinson's disease.
25 8
Until
Th~
/lle<vOI" Sy'tem
Adwrse Effects
amantadine (Syrrmeutl)
apomorpline
brornouine (Parkdtl)
tarbidop;t~e l'Odopa
(Sinernet)
ffitaYpOne (Corntan)
In odopa (l.{)opa.lirodopa)
IItINTOCI'luarinpm
PO;StJrt with o.m mg tid for 1wk;doublt thisdosr for tllt nelt
W'k; (ontinue to iOOl'.l SI' b1 O.1S fll9/dose ~d !'Vl'IY Wl'ek 10 a
target dosr of 15 mg tid
PO;Soo with O.1S mg tid; may illll'aII' by 0.25 mgfdosr Tid ~'Il'1)'
WffI: to i tir~T dose of 1 mg Tid
"""'"
tokapone (filmar)
~,
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mar ). Side effe,ts of COMT inhibitors include mental confusion and hallucinatio ns, nausea and vomiting, cramps,
headache, diarrhea, and possible liver damage.
''''PIf, 20
fIie,,,,,,,. 5)'-aem
259
PHARMACOTHERAPY ILLUSTRATED
Progressive
deg-eneration 01
neurone in the
rign>!llriatal
palhw"'lcan
Aniipeydlotic
dopamine blocking
"",.
ptOduc,,:
-" l:J (1
Corpu triatum
striped body'"
SIown_ 01 movemenl
(bradyki.--is)
LOSII 01 balanc"
8 ......llJIIngl..
Inlemal capeule
~olslNctures
10ITT"0S" slripe.
Anrichofinergics
Anticholinergics inhibit the action of acetylcholine in the
brain. They are used early in the course of therapy for
Parkinsonism disease.
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260
Until lheNetv"",,Synem
Levodopa (Larodopa)
ADVERSE EFFECTS
Sidt t1feds of Irodopa in(kIdt unc:ontrolled arod purpost1tss m~mtntl sum
astIItffiding the fingm arod shrugging the shoulders. involuntary IIIO'/ tmtnts,
loss of appetitt.nausea. arod vomiting.Il'uS(1I' twitming arod !palmodic: win king
aft'tarly sigru of toxicity. Orthostatic hypottnsion is (ommon in SOmt palitntl.
TIlt drug shoold lit dilwntinued graduall): bKaust abrupt withdrawal Ll nprodiu oKUtt Jlolrkinsonism.
Contraindicilti ons: L.evoOOJlol is (ontraindicated in tilt tft'atmtnt of narrowang1l' glalKOOIa. panic:ularly in patiffits with suspic:ious pigmtmed lI'sions or iI
history of mt lanomi .This mtdicalion should lit a"loided in m~ of lrutt ply(hoII's and I!'YtfI' psydlonturosis within 2 wtth oftht rapy with MAOI.
INTERACTIONS
I)ug- l)ug: If'iOOOpa inoom with many drugI.For~.tric)dc:
Plfgnanc:yLlltgOry C
PHARMACOKINETICS
IAlset: L.m than 30 min
Peak: 1- 3h
Half~ife: 1 h
Duration: Variablt
lfN
TABL.E 20.3 1 Anticholinergic Drugs and Drugs with Anticholinergic Activity Used for Parkinsonism
Routeand Adult Dole Imax dose where Indl(ated)
Drug
Adverse Effects
bffiztropiotmt~lt (Cogentinl
biptriden hydrodlloridt (,i,kiotlonl
diphtnhydramirH' hydrod"jorid.: (Btnadryl) (~
~ mlorl,"", ProIotyptDrug IHD: OO)
5tdJio~ _.Il!frjripo~on,lty
-=-
.. ~ .dwrl!' .n.m.
IrditJ indici"<OIIImon~.rrM';~iodicil
FIX lirf(.ltooflirlgplO(tsJ ~roQMidI<MllfrgK Iht~ wNriflirlg Procm FooIs:Pariennlktimg Amidloliotrgk rhfrop%pogt 145n d!op/tI 1]0/0.
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Assessme nt
f.milyor~'lntt!led.
lsHllmtnllhroighoulldminillration:
Aistil for dnirtd thr"pMic riIeo:ndfpmdtm on tht rUlOn for thtdrug
(t.~, dKrtMtd trtmon, briClytint~, rigaty).
Continue ptriodK monitoring of viI.1 sigm,lIlI'mal stJrus,.nd motor
blctiolL
AtSs for ,nd promptly tfport ,dvtrstefftru:trypottfllioo, incrt.sing
tmnm,diczzinm, lliotatiDn,.noft'lia,~gia,or dJ.ngtI in menul
lIillI!, including .gitatioo orcoofll!ion..
Planning: Pltle nt Go als and Expected Outcomes
--+--
Imtruu tilt patimt to GaU for i11lislanct prior to gtlli!19 out of bfd or
,ufmptill9!owalk .Ionf iflndytinf~, riIjcIity,or tltlllO/\.1t
""nirularlylfftlt.
Assffi tilt pititm'~ lamily'~or uttgim'uolity to tiItfJ out ADlUl
homt.nd ~ tilt n~ for additional ht.1th Galt rtfmIls. [v,kiilf
homt lftl)' rwdi.
(Conrtnued)
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Tfh tIM- piltitm 111 ~ from IyWog 10 Iitmg 01 SQnding slowly to;woid
dizzinm orlalls.
m.ata
s..
Ac!vist 1M piltitnt tfIat UriM 01 swt'at m.y darRo and uodtnhirl5 01 dress
shitkk mily help 1O...aid IUining of clothing.
The piltitfll, filmily,or CilrtgMr shoule! be ilblt to state thf Il'jSOfI for ~
cWg;appropriiltf dow .nd Khed.rling;.nd wfoill iI!Mrw~ 10
oto_ for iI1d whrn \Q Il'port.
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HOME
&
COMMUNtTY CONSIDERATIONS
ALZHEIMER'SDISEASE
Alzht'imt'r's dist'ast' is a dt'Vastating, progressivt', degt'nerativt' disease that generally begins aftt'r age 60. By age 85, as
many as 50% of the population may be affected. Phannacotherapy has limited success in improving the cognitive
function of patients with A1zht'imer's disease.
20.5 Characteristics
of Alzheimer's Disease
Alzht imtr's disrilsr (ADI i. responsible for 70% of all dt'mentia.
Demrntia is a degener:ltive disorder characterized by progressive memory loss, confusion, and an inability to think or
commlUlicate effectively. Consciousness and perception are
usually unaffected. Known causes of dementia include multiple cerebral infarcts, sevt're infections, and toxins. Although the cause of most demt'ntia is unknown, it is usually
associated with cerebral atrophy or otht'r structural changes
within the brain. The patient generally lives 5 to lOyears following diagnosis; AD is the fourth leading cause of death.
Despitt' extensive. ongoing research, the etiology of
Alzheimer's disease remains unknown. The early-onset fa-
~ Prototype Drug
Benztroptne (Cogentm)
lh~
(orpul miatum.k
isulf<! for ft'litfof parkilllOllivn s,mptoms and ~r tilt IIutmrnt of EPS brought on by amipsycoolir: pha!T11Koliltrapy. This IMdiution
WPPft'lSf! I~mors but rIot>s not afftcl tJrdi~ dyskinrsia.
ADMINISTRATION ALERTS
nY,
PHARMACOKINETICS
Onwt: IS minlMI1V;1 h PO
Pfak: 1-2 h
Halflife: 2-3 h
~on:&-10h
ADVERSE EFFECTS
"" rlp!"llc"ll [,"111 it> .ul"IIOm;" liun, bnlllrupin" ,.n uu .. typiul .nl~
(holinergK side rfrecu IIKh as d!)' mouth, conniparion, and tam)n!lh. AdYmf ~al ffltch indudr Sfdition, drowsillfS~ diuinflS, ft'It~YIf"I~
iniubiily. nelVOlMfS~and insomnia.
Contr.indi u tions: Contraindiutions i!l(lude narrow-.Jnglt glaIKoma, myas-.
theni<! ~rnis,.J nd obltruct~ diINlrs of tht gen nOUfina!), and Gl mID.
INTERACTtONS
nY,
La b Ii5IS: l.Intnown
Herbi~Food: Unhown
Treat mt m ofDlfrone: Physostigmine salKylatt.110 2mg wbrutlntoJslyor
IV, will lt'\'erst symplOtnI of anlidlolin. rgir: intoumion. A!oKond injt(ticn tna)'
bt 9N!n aittr 2 hours, n ft'I[uift'll. OtherwiM', UNlm. nl is symplomali!: and
supportivr.
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>
l
"
."~
26 4
Unlll Thl'Ne<voo,Synem
Acetylcholinesterase Inhibitors
(Parasympathomimetics)
The FDA has approved only a few drugs for AD. The most
effective of these medications act by intensifying the effect
of acetylcholine at the cholinergic receptor, as shown in
Pharmacotherapy Illustrated 20.2.
TABLE 20
Drug
PO; 5- 10 mg ,t btdtim~
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Adverse Effects
Iwdod'f,dillifJt!~ immmi4 fJQlIItIJ,dQ~ romiring,
HepatolCJ:idty
''''Plfr 20
265
PHARMACOTHERAPY ILLUSTRATED
20.2 Alzheimer's Drugs Work by Intensifying the Effect of Acetylcho line
at the Receptor
Cholinergic: nuuron-
Normally:
o Ach is .",..."ad.
Normal rde 01
E) Thu action 01
--no
memrrntino
in a v... t array
Ach is terminatad
by AchE.
ofbrain
functioN ,
incUding the
o inhibited. Ach is
H AchE is
ability to
speak, """"'.
.......
notbroken down
as quickly and
producea a. mON
dramatic: ellec1.
.... think,end
ChoIine.gic .eceptor
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elimination. There is evidence that memantine may be effective in the treamlent of vascular dementia.
Although acetylcholinesterase inhibitors have been the
mainstay in the trea tment of AD dementia, several other
agents are being investigated fortheir possible benefit in delaying the progression of AD. Because at least some of the
266
Until
The
/IIeIv"",, System
Donepeztl (AT/apt)
Pharmacologic ( lass:
Acetylcho~nesterase inhibitor
ADVERSE EFFECTS
Common side tffNII of dolll'ptzil all' vomitioo. diarrhea. and da~ed urine.
CNSside eflecli include insomnia,syncope, deplI'Ssion, headKhe, and initability. MlJI(uloili leta Iside efleo:t; inckKie mUl(Ie cramp!, arthritis, and bolll' hcNit!. Gene~lizM sid~ effects includt Ile~t, iabgut, cileIt p.lin, inCII'.lIM
libido,hot 1Lt!hts, urinary incontilll'lKe, dehydl'iltion,and bkmM vision.
Unlikt with tmilil', htpatotOlic:ity has not been OOsmed Patients with
brad)uldia, h)'potension, asthma, h)'perth)'roidism, or "'ti!' peptic: uker disease Ihould lit monitoll'd carefulI)'.
Contraindications: DolII'p!'zil is contl'ilindic:a!ed in p-atienll with 61 bftding
<l ndjaunditr.
INTERACTIONS
PII'9I1aIK)' <alf901)' C
PHARMACOKINETICS
Q-/set: Less than 20 min
Pt,ak:Hh
Half~ife: 70h
Duration: Variable
fffm~,phfn)1oin,~,andrfMllpilmay!pffd!he
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MULTIPLE SClEROSIS
Multiple sclerosis is a chronic, inflammatory, autoimmune
disorder found most prevalent among young adults. Sensory and motor deficits become progressively worse as the
patient grows older. If treatments are started early, the frequency of disease symptoms can be slowed and permanent
neurologic damage can be delayed .
20.7 Characteristics
of Multiple Sclerosis
Multipl! sclerosis (MS) is a disorder characterized by damaged
myelin located with the CNS. Antibodies slowly target and
destroy oligodendrocytes, myelin, and axonal membranes.
As axons are destroyed, this impairs the ability of nerves to
conduct electrical impulses. Inflammation accompanies
damaged tissue, and multiple filamentous plaques called
scleroses are formed. During the early stages of MS, some axons recover due to partial myelination and the development
of alternative circuitry, but as antibodies continue to attack
neural tissue, further damage and infianullation lead to
neuronal death. Patients often bave recurrent episodes of
neurolo~icdysfunction, which pro~ress at a fairlyrnpid rate .
(""'If I 20
267
Adwrse Effects
IMMUNOMODULATORS
Oizzi~ hwIocht\. Wfaknru,ronillli<l1. Qntry,
mtmd dfprruion,(miJn(/jy;m.irrhi~ rDMII,
KlmitirJ;,ronJripOOon,diorrlIto,I6l!Q/dyifrJnrOOIi,
IWNri~ mmsrrua/ dilordm,.lIMIOfHrio,. ~kf
mpoIymtrIJ
intffifron bttI1~ (A~x. 1Imf)
SC;2S0f1l(gMIYOIlltfda,
nat~lizum.lb (T)'Iabn1
sympfOm\.!pIISIkily,~ ll'O(~m
ar IIw injKoon w
SMm,inap/rllam,hmalotoximy!p!U!'tOusilgJim
IMMUNOSUPPRESSANTS
mitoxantront (Ncwantront)
IJrdiot!1);Ki!y'dys!!rtthmY shorioessolbrtith
The etiology of multiple sclerosis is unknown. Many clinicians and scientists suspect genetic or microbial factors
due to reports that in most cases, MS occurs in regions of
colder climate. One thooryproposes acquired immwlOlogical resistance against pathogenic factors in warmer climates.
Microscopic pathogens such as viruses have been sU88ested,
though there is not slrong evidence for this theory.
Signs and symptoms associated with axonal injury indude fatigue, heat sensitivity, neuropathic pain, spasticity,
impaired cognitive ability, disruption of balance and coordination, bowel and bladder symptoms, sexual dysfWlction,
dizziness, vertigo, visual impairment, and slurred speech.
The course of MS is unpredictable, and each patient experiences a variety of symptoms depending on the extenl and
localization of delll}'\'lination.
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26 8
Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the (hapter. If any of these points are not dear, refer to the numbered se<:lion within the (hJpter for review.
20.6 Acetylcholinesterase inhibitors are used to slow the pro gression of Alzheimer's disease symptoms. These agents
have minimal efficacy, and do not cure the dementia.
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The nurse discussed the disease process of multiple sclerosis with the patient and caregiver. What does the nurse
explain is the cause of AD~
1. The cause is unknown. Amyloid plaques and
neurofibrillary tangles have been found in the brain ~ t
autopsy.
2. The cause is unknown . Manyscarslocated throughout
the brain have been foulld 011 MRI scans.
3. Loss of circulation to the brain has been found on MRI
~
II
following?
l. Orthostatic hypotension
2. Drooling
3. Spasmodic eyewinking and muscle twitching
4. Nausea, mmiting, and d l1rrhea
to
mUd lndlgeslloll, and also takes multivitamins dally (vItamins A, B" D, and El. She also has a history of diabetes
mellitus type 2. What ~ouJd the nurse include in teaching
-----==-i~-----,
3. A 67-yeu-old Alzheimer's patient is on donepezil (Arlcepl ) and has a history of oongeslive heart failure, diabetes
mellitus type 2, and hypertension. The patient's wife asks
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~LORE ~
M)NImllngKllIli \'OUr one SIIJII !er anllfII! c!laptlf lB'fiew mmeriols and
ruourcet. Prepare lor ~ess wim aaditional NClEX"~e practice
Q~ irrhr.lctilltlllSlOgm>IIIis lnI ao;ti'lities. WIIb I~ anDil\i0n5
and vicIoos, and mae!
DRUGS AT A GLANCE
LEARNING OUTCOMES
Nondtpolarizing81ocktrs
~ arizi ngBlocb rs
,.]78
PfIfItm
KEY TERMS
doniupmn paqt m
dystonia {lDgt 171
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nturOlllU5CUlar bIcKlim
paiJt lIS
o..plfll1 DrugsfOfNI'U.omusrularOlsor<ier,
most difficult conditions to treat beca use their underlying mechanisms span other important systems in the body:
the nervous, muscular, endocrine, and skeletal systems.
Proper body movement depends not only on intact neural
pathways but also on prope r functioning of muscles,bones,
and joints (chapter 4700), which in tum depend on the lev-
271
PHARMFACTS
Muscle Spasms
Moll' than 12 million PfopIIo worldwide hal'!' musc:1e 'p,nm,.
MUl(le!palms Il"'Il' t llOU9h for drug ther~py ~Il' oftt n found in
piltitnts who h~I'!' othtr dtbilitating disonle~ SIKh II mokt, inju!)',
ntUrodegener<lliYedise.J~, or U'lt'br~1 pillS)'.
Cmb~l p~lS)' is usu~lly i!5O(iattd with n'ffill that O(cur btfort or
dJring birth, but miy lit acquired during tht fi~t ftw months or )'Nnof
life II the ~k ofhtid trauma or inftion.
Dystonia iffKts iboot 250,000 JlNple in the Unittd StattS; it is the thild
most mmmon moY!'ment disordt~ following esltmial tll'mor ,nd
Parkinson'ldisem.
Rrl!'ardll'~ ha~ ft'(ogniZl'd mukiple fonmofinheritable dystonia ,nd
idtntified at lem 10 getlHor(hromosom,llo!atioll! Il'sponsible for tht
mioul maniftst~tionl.
MUSClE SPASMS
MUlde spasms are involWltary contractions of a muscle or
groups of muscles. The muscles become tightened and develop a fIxed pattern of resistance, resulting in a diminished
level of functioning.
21.2 PhlllrmlllcologiclIInd
Nonpharmacologic Treatment
of Muscle Spasms
Treating a patient with complaints of mus.:le spasms requires
a careful history and physical exam to determine the etiology.
After a determination has been made, nonpharmacologic
therapies are normally used in conjunction with medications.
Nonpharmacologic measures may include immobilization of
the affected muscle,application of heat o r cold, hydrotherapy,
ultrasound,supervised exercises, massage, and manipulation.
Pharmacotherapy for mU5Cle spasm may include combinations of analgesics, anti-inflammatory agents, an d centrally acting skeletal mU5Cle relaxants. Most skeletal muscle
relaxants relieve symptoms of muscular stiffness and rigidity resulting from muscular injury. They help improve mobility in cases in which patients have restricted movements.
The therapeutic goals are to minimize pain and discomfort,
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th~
patient', ability
272
Unlll Thi'Ne<vDI"Sy'tem
Route and
IOOoI'ffi (Lioman
cariIoprodoi (SofN)
dllorphen~n (~I~ )
PO;lSOmgtid
PO; 800 mg tid 1Il~1 dfMiw'; rt'duu to 400 mg qid orlm
Adverse Effects
l"Jr<:wtJint55,dizmts~dry
bradta!rdQ
[dtrna of 10m. anaphylagi< rt'a(!ipn, rrspiratO!Y
deomsjoo.(oma /aryngo>Mm.wdmw/ar(o!!apse
~myldays
FIo.rol)
diazrpam (Valium) (1ft' palJl' m for
(Robaxin)
lizanidilll' (bnaflex)
Prototype Drug
ADMINISTRATION ALERTS
Th~ drug ~ not rt'(Ofllmtnded lor ptdimic: 1M.
Mn imum effKh may tau 1 to 2 weeks.
PrrgoallQ talf90lY B
ADVERSE EFFECTS
~rst rrauions to (){Iob~nzaprin~ indude drowsinffi, blurred vision, dizziIII'SI, df)' mouth, rash, and tathycardi.l. 0111' rt'~aion, ikhough rarf, is swelling of
thetongUl'.
Contraindiutions: CydobtnLlprilll' should bf used with mnion in palitnu
with MI, d)'srh)'thmias,orlf\'t'r~ uroio-lwlardis~~SI'.
INTERACTIONS
~-Ilfll!l:
iMililll" (lMClI thtrapy III'Yus.! "II5P'1"fNk (risis and torII'Ulions may oml".
Lab Tests: Unl:nom
IWrbaVFoo:l: Unknown
T~tment
01 OYl'rdose: TIw
im~nous
administration of 1 10 1 mg 01
PHARMACOKINETICS
1h
()}stt
Pt,a k:l~h
HalHiflo: l- ldays
Duration: 12- 14h
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qdobtnzaprin~ ~.
SPASTICITY
Spasti city is a condition in which certain muscle groups remain in a continuoui state of contraction, usually resulting
from damage to the CNS. The contracted muscles become
stiff with increased muscle tone. Other signs and symptoms
include mild to seVtre pain, exaggerated deep tendon refiexes, muscle spasms, scissoring (involuntary crossing of
the legs), and f~d joints.
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274
Unltl TheNe<vomSy,lem
PHARMACOTHERAPY ILLUSTRATED
21.1 Mechanism of Action of Direct-Acting Antispasmodics
Spaeticity.
s...,......... oontncting
Admirielnltion of . ntiapurnodic.
Dantrol _
Symptoms:
(Dantrum) bIocke
Pain
InvnobOlity
lnabiity to perform ADl..e
Myofibrilo
\
(myosin)
R89Ult of druI:Ilhempy;
Reducad pain
Mobility
Greater ... nge of muscle activity
Initiation of new
Relaxed muac:l...
impul ....
Adwr,e Effects
NEUROMUSCULAR JUNCTlON
SKELETAL MUSCLE
Q
~ntroIene \Odium
(Oantrium)
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HrMk ncrut;
&
H OME
C OMMUNITY CONSIDERATIONS
MUI(Ie sp.nms and !pa!tic:ity aft' ronditions that rna)' .Jlftct patients ttroughout thtir life span. In tocIay'swciety, many of the patients who in t'le past
rtIidtd in nursing hollll'land institutions aff now being urtd lor at h:rnr by
famiy members and horn!' heath aogeoc:it1.AIso, the nrurologic: disulI'I that
alftrt young arults aft' bti ng ~ated in the horn!'{(ommu nity sfning. Thus, all
igf groups aff able to be with thtir famil)' mtmbel'S and li~ as nollllli a life
as possiblt. T~ main factor to ffmember is that fdKation and ~pport for
u regil'll'rs is trtlt'me/y important to en~ring that patitnts aft' (ompii.-!t with
thtir therapy and that u regiven aff (om pttfm10 admin isler the t~rapy.
ADVERSE EFFECTS
D<antrolene is often used for spasticity, flpt(i.lI~ for spasms of the hrad and
III'dt It diff(t~ reinf1 musde spasms by int~rferin9 with thf ffl~.N of (alciu m
ions from I10fq affas imide skeletal mUl(Ie (fils. It dot-s not afiret (ardi.l{ or
,",ooth mu!Cl<. O. mrolen< ;. ~'p<ciolly u..tirllor mu,d~ 'POID!' wI>< nIl><y 0<wr after spinal (ord injury or strokl and in ta\f"I of (frm-al palsy or mukiple
~is,and oc:taSion~l~forthe trtaDntm ofmusc:1e pain ~fter hNl')'l'XI'f(~.
k is ilso used fort~ tffalmtm of malignant hypMhennia.
ADMINISTRATION ALERTS
U~
oral
!U~sion
btU!M
pr~lYilm.
PHARMACOKINETICS
Onsrt: 1~2 h
~k: 5h
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INTERACTIONS
Drug-Orug: ImIr<Wfle n\m[\S with many O!hef drugs. For e1am~, ~ moukilKll
bf tal:et withOT( lWgh ~ andantiJistJninei,akohol,Of OIher OiS
dtpres5.ln1l. Verapamil and other ukiOOl dIanneI bbders liter. with dan~!
inuNII the riIk ofYflltriruiaffibrilalioo iIIld urdc'Iilsuur~.
libTi5Is: I..Inkncwn
Herbi~Food: Unknown
Treat mf m of O"ft'rdosr: For awtr amONgf, gentral IUpportm mHlUr6
should be ustcl.
III'I'fr Ii1 MjNUrllngm kif Q Nlmlfll} I'rIKn.! fool! J{lKIk Ii1 rIr/s dnii}
"
276
Unlll "TheNelvoo.Sy.tem
Assess ment
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Instruct the patient to (oJ II lor as sistanc:t prior to getting out 01 btd or
atttmpting to walk alont if piin, spism~or rigidity ,ft' panicularly II"Ifrt.
As= the pitient~ familis,or (;I~sabilitytoGlny outADLs at horntand
tJ:pIoft' nttdfor additional htalth GI~ Ifierrolls ifdisabi~ywil rrqUR long.
tmn physical thtrapy (e.g., cmbral palsy). Evauate horne safe/)' nttds.
InstllKt the patient to iwid driving or other actiyities requiring men!al
,Ion_, or ph)'lial <oordin"ion unt~ tilt ri"Kts of tho drug Ire known.
(onlilut III monifDr vOl sic}ns, pirticularly blood PfmUIt. TiR ~ blood
pttUUIt IyiIg, ~iting,lnd stMllling fD deiKt orthost.tic hypot~miotL Be
partiwl.lrIy c.wtious with 0& adults wfto if! i11.n m:~~ risl for
~sion. HoI:ify tile hNIth Un! pmider if thf blood pl!SWIt
le~ tht p.u itftt to rise from lying 10 ~ Of !landing !lowly to ft'Oid
IiuftsSOf his if sight h,poffmlon noI:td.
"-lilt pitimt im~eIy rtpOrt dizziness, lighl~
pilpiutions, Of 1)1ICOpf.
Incltue l\Jid inlilke uod dietary fibfr waR 10 ptntnl GI tfftcts and 113
NSf dry mouth efft<u. (MII$(Ie ~.w" d:nI.p 1M)' dltile peri!1iI1sis II
an .MM elJt. SigNlicandy dininished Of ibstnt bowm!GU1Id! a~
imrnf'Cia,tdy Itpolled to the hti/tll Oft ~. AdditioMll\Jidi and
Iibtr may est conltiprition and PfMIII diIrrht. but.dcIitionaI
mtdiutiofls sudllS Mnlar OfCcllce
1M! ~u~ if !he constip.tion
isWlm.l
Tt,ch tht p.ltient to iIaNst lluick to 2 Lptf d.y ind inut'le the inlilR of
d'.wry fibtr such IS fruits. Y!9tUbIes,.nd whoIt 9'ains.
InstlllU tilt patitnt 10 Itport W\Itrt COllStip.ltion to the health Cillt plOYidef
for Miditiollfl td'fia: on iliUM Of stool sof1tnm.
m.I,
InstrucllM
immrdNttly.
Tht Piltitnt slloukl be ilble to stitt the ltiiSM fonflt d~lppropriilte dose
and schedulin!l.nd whit id'l'trst tflt<lS 10 obstM for ind whtn 10 report
thom,
TI .
Instruct tht prititnt in plOPtf idmiMtrarion guiddinn. Tht dow should 1M!
takefl consineflcly i1nd not pm for best
unIes othtfwist onItl!d.
(1ICIlUIaC}t 1M lIiIitnt to mMtMn .1I'IediCMiOn log. naIing symptoms.1ong
with dostlnd timilg ofmtdic.arions.nd bring lilt lag louch hullh COI~
mit
EVAluation of Outcome Criteria
kahYIt tht ~I of drug thtr.py b,. confirmilg "'" piUrftt 90111 a,nd ~ outtOlllH haw t-I mrt (Ite "Planning").
Sfto lII*lJI.I n 11.J"1st!: dhfS /Ow/WidtetllWli,..m-qpIJ.
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Of Itwo.!
278
UnltJ
TheHe!vous~!tem
longer surgical p~ures (Table 2J.3). Although not preferred for mechanical ventilation or endotracheal intubat ion,
small doses of these agents may be used for intermediate surgical procedures (chapter 1900 ). Concerns of tubocurarinelike tre;atment are over-rdaxation of muscles. As examples,
normal breathing activity (involving the diaphragm, and
glottic and intercostal muscles) and swaUowing act ivity (involving the neck and certain esophageal muscles) require
contraction of skeletal muscle.
Depolarizing agents aJe used primarily to rela.'\: the muscles of patients receiving electroconvulsive therapy (ECf)
(cha pter 1500) and for shorter surgical prQCedures, for eJ\ample, mechanical ventilation and endotro cheal intubation
(chap ter 190"0). Succinylcholine (Anectine. Quelicin) is
the prototype example of a depolarizing blocker. Adverse
effe-cts include persistent paraJ~is in some patients, elevated blood levels of potassium. ma lignant hyperthermia,
and postopt'tative muscle pain. A5 a specifK antido te for
persistent paralysis, patients are often given cholinesterase
inhibito rs. Cholinesterase inhibitors also represent a form
of th eropy fo r diagnosis o r treatment of myasthenia gravis
(chapter 1300) and for the treatment of Alzheimer's disease (chapter 2()OO) and glaucoma (chapter 490'= .
itOOIilll1 (TrolUiwn)
Long dll"ion; IV
dwtracurilll1 (JrimbeJ)
Long dll"ion; IV
rIIN.KIIi1ll1 (Mifauon)
Shorttr IiJfation;lV
panatfOllilm (P,vulon)
Long dll"ion; IV
pipMRllilll1 (Arduan)
L~ dll'tion; IV
rorurooium IZmllIOO)
Long dll"ion; IV
t\boaQri~
vocwonilll'l (Momnn)
Long dllilion; IV
DEPOLARlZtNG BlOCKERS
Wi"khoIi~ dllarklt tAntj~()Ididn) II pq
~lm oooJ
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CIIopltlll
279
. Chapter REVIEW
KEY CONCEPTS
The numbered kt-y concepts provide a succinct swnmary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
Cydobenzaprine{Cycoflex, Flexeril) is prescribed for a pa tient with muscle spasms of the lower back. Appropriate
nursing intervention would include: (Select all that apply.)
I. assessing the heart rute for tachycardia.
2. providing for patient safety.
3. encouraging frequent ambulatiO/l.
4. providing oral suction for excessive oral secretions.
S. assessing for rash.
A patient who was prescribed cydobenzaprine {Cycofle:!:, Flexerilj reports taking propranolol {Inderal} for
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II
280
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EXPLORE
~.------,
U NIT
The
Cardiovascular
and Urinary
Systems
CHAPTER 12
CHAPTER 23
CHAPTER 24
CHAPTER 25
CHAPTER 26
CHAPTER 27
CHAPTER 28
CHAPTER 19
CHAPTER 30
CHAPTER 31
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Chapter 22
Drugs for Lipid Disorders
DRUGS AT A GLANCE
LEARNING OUTCOMES
..
"
~~
Q cholesryramklp (OUes/ran) p:xJt 291
KEY TERMS
ipoprouin (lQ9tl8J
.therosdtrosis tG'II'183
bilracidmin (!QtIt189
dyslipidemia pI1jl185
high-density lipoprotein (HDl)
HMG.CoA ~ductaS!' paqt 187
{OJ1183
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Choptor 12
helped identify those patients at greatest risk for cardiovascular disease and those most li kely to benefit from pharma-
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283
PHARMFACTS
22.2 Lipoproteins
Because lipid molecules are not soluble in plasma, they must
be specially packaged for transport through the blood. To accomplish this transport, the body fornlS complexes called
lipo~teins, which consist of various amoWlts of cholesterol,
trigl)"cerides,and phospholipids, along with a protein carrier.
The protein component is caUed an ap~rotein (apo- means
~separnted from or derived fromW).
The three most common lipoproteins are classilied according to thei r composition,size,and weight orden6ity, which is
d ue primarily to the amount of apoprotein present in the
complex. Each type varies in lipid and apoprotein makeup
and serves a different function in transporting lipids from
sites of synthesis and absorption to sites of utilization. For example, high-density lip~rotein (HDL) contains the most apoprotein, up to 50% byweighl. The highest amolUlt of cholesterol
is carried bylowd~nsity lip~rotein ( LDI.). ~ Figure 22.2 illustrates
the three basic lipoproteins and their compositio,lS.
To understand the pharmacotherapy of lipid disorders, it
is important to learn the functions of the major lipoproteins
and their roles in transporting cholesterol. LDL transports
cholesterol from the liver to the tissues and organs, where it
is U6~ to build plasma membranes or to synthesize other
steroids. Once in the tissues, cholesterol can also be stored for
later use. Storage of cholesterol in the lining of blood ressels,
however, is not desirable because it contributes to plaque
bu ildup and atherosclerosis. LDL is often caUed abad w cholesterol, because this lipoprotein contributes signilicmtly to
plaque deposits and coronary artery disease. Very low-density
lipopr~ein (VLOL) is the prim3ry carrier of triglyceride:s in the
blood. Through a series of steps, VLDL is reduced in 6ize to
become LDL Lowering LDL levels in the blood has been
shown to decrease the incidence of coronary artery disease.
H DL is manufactured in the liver and small intestine and
assists in the transport of cholesterol away from th~ body
tissues and back to the liver in a process Cllled re"R~ moles
ttroltransport. The cholesterol component of the HDL is then
284
H- O -CH
I
H-O-CH
H- O - CH
Fatly , eid.
'----:'"
:c.,~
cc:,----~
~.c'------------------------:~
c,CyC~v
c.:~c,c.-----------------------"
( Hyd(ophl~e)
(Hydrophobic)
beckbooe
,H,
HC - CHl
I
CH,
,H,
I
CH,
I
HC - CH,
CH,
CholestefOl
(e) Steroid.
,.. Flgure22. 1 Chemlcalmucture of lipids
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Testostomne
Triglyaorida
Phospholipid
P",tein
Cholestorol
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Although high serum cholesterol is associ.1ted with cudiovascular disease, it is not adequate to simply measure total
cholesterol in the blood. Because some cholesterol is being
transported for destruction, a more accurate profile is obtained by measuring LOL and HOL. The goal in maintaining normal cholesterol levels is to maximize the HOL and
minimize the WL This goal is sometimes stated as a ratio
of LOL to HOL.lf the ratio is greater than 5.0 (five times
more LOL than HOL), the male patient is considered at risk
for cardiovascular dis<!ase. The normal ratio in women is
slightly lower, at 4.5.
Scientists haV\' further divided LOL into subclasses of
lipoproteins. For example, one variety found in WL, called
lipoprotein (a), has been strongly associated with plaque
fomlation and heart disease. It is likely that further research
will discover other varieties, with the expectation that drugs
will be designed to be more selective toward the "bad"
lipoproteins. Table 22.1 gives the optimal, borderline, and
high laboratory values for each of the major lipids and
lipoprotein .
Establishing treatment guidelines for dyslipidemia has
been difficult because the condition has no symptoms, and
the progression to cardiovascular disease may take decades.
Based on ongoing research, the National Cholesterol Education Program (NCEP), an expert panel of the National
Heart, Lung, and Blood Institute, periodically revises the
recommended treatment guidelines for dyslipidemia. The
current guidelines are based on accumulated evidence that
reducing "borderline~ high cholesterol levels can result in
fewer heart attacks and fewer deaths. Optimal levels of LOL
cholesterol have been lowered from 130 mgldL to 100 mgldL
HOL cholesterol should now be at least 40 mgldL, compared with the previous 35 mgldL. In addition, the NCEP
guidelines recommend that high cholesterol levels be
treated more aggressively in people with diabetes, and that
hormone replacement therapy not be considered as an alternathe to cholesterol-lowering medications.
286
UnII4
Th<>(~ rd""'.",ul ..
many patients taking lipid-lowering drugs also have underlying cardiovascular disease, these lifestyle changes are particularly important. To emphasize the importance of
lifestyle changes, patients should be taught that all drugs
used for hyperlipidemia have side effects and, to the extent
possible, that maintaining normal lipid values witham pharmacotherapyshould be a therapeutic goal. FoUowingarethe
JIlusl iJJlPucl~lll lipid-c"d u~Liun li["",l rlt< inl"cv,,"tiuJls,
LaboratoryValue
(mgldL)
Standard
ToIII~troI
<'00
~rabllo
LDl~troI
l1-m
Borderi~
>219
HiIj1ri51::
I <100
100-129
HOLdloitsttrol
TrigIy(ffidel
~imil
Bordtri~
160--189
>100
HiIj1ri51::
high risk
\lHyhighrisk
low
<>"
Bordtri~
>W
~!irabllo
<IW
Ne.uorabow optimal
1l1>-159
I <~
high risk
high risk
....,
1>0-199
'<100
COH"
High ri51::
\lHyhighrisk
L IFESPAN CONSIDERATIONS
Pediatric Dyslipidemias
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Chopltl12
28 7
~el1.<
o n the
cere.ls, and some fruit juices. According to the AHA, the recommended daily intake of plant sterols or stanols is 2 to 3 g.
HMG-CoAREDUCTASE INHIBITORS/STATINS
The statin class of antihyperlipidemics interferes with a critical enzyme in the synthesis of cholesterol. These agents,
listed in Table 22.2, are first-line drugs in the treatment of
lipid disorders.
l~horMory.
Thi.< d ...<..~ of
dnJg~.
koown
~.<
the
sit/tins, has since revolutionized the treatment of lipid disorders. Statins can produce a dramatic 20% to 40% reduction
in LDL-cholesterollevels. In addition to dropping the LDLcholesterol level in the blood, statins can also lower triglyceride and VWL levels, and raise the level of ~good" HDL
cholesterol. These effocts have been shown to reduce the incidence of serious cardiovascular related events by 25% to 30%.
""rf~ce
of liver
~elk
Adverw Effects
ftuViSLuin ILflll)
IUiiSLllin IM~ilJll)
piLlViSLllin ILNalo)
pramlllln IPriVadIot)
J05lNalliti1 (Cmtor)
~m\\llLllin
]Zoo:or)
PO;S-40 mgldaylmal:80l119iday)
mI=-'tlilm (WeidtoI)
mI~ipd lColtltid)
pruriJJJl
Rhabdomyoly~ ~
smn: my9Iiti!
-.
dofibralt
l~tromid-S)
Q gemfibroli ILopid)
Cholelithiasis. pa!\{I!~~tis
OTHER AGENTS
Hypmpidmlia:PO; 10 mglday
mlimibelZtti.l)
pm diarrirfo
fMMg.lICIU!f4pruriflJl,heododtt,bIoorirrg.diarrirfo
lIatindelidtnq:PO;l0 lOmglda,
DrnIriIlvniu
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"
"
I
;;
288
.......
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Much research is ongoing to discover additional Iherapeutic uses of statins. For example, statim block the vasoconstrictive I'ffect of the A-beta protein, a protein
associated with Alzheimer's disease. Cholesterol and A-beta
protein have similar effects on blood vessels, causing them
to constrict. Preliminary research suggests that the statins
may protect agaimt d",mentia by inhibiting the protein and
thus slowing dementia caused by blood vessel constriction.
Research also suggests that the statins may have the ability
to lower the incidence of colorectal cancer. Several attempts have been made 10 move low doses of certain statim
to OTC status; however, the FDA has not approved these
applications.
ChoIU,12
2B9
PHARMACOTHERAPY ILLUSTRATED
22.1 Mechanism of Action of lipid-lowering Drugs
Statin.
Interfere with HMG..coA
reductase, the aitical
enzyma in the bioe}<IthMis
01 choIeatOi
Niac in
Dec""""", both VLDl
and LDlfe""fe
.....
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Ezetimi be
Bloc"" the abeorption
01 cl>oleslerollrom the
small inl""t ne
2110
UnII4
Atorvastatln (Llpltor)
ADVERSE EFFECTS
~~ rfffCts of aTol'/aStatin IiIrt1y Iusr distominwtion of therapy.
HradldJr and GlllImpl.inu 9Jlh .s inttstinal mmping. diarrhea,.nd (onstip.tion art (ommon dUling therapy.A sm.1I ptl{et"l\lgt of ~tirnts rlperirnuo
Irmdam.gt;rhus, lIt~tic fur.ction is monitoltd during tilt fim few monrhsof
therapy. Tht most srrious adYent tfir(t is rh.bdomyol)'iis.
Contrain dications: (ontraindiutions intkKlt serious lim dise.1!', unoplaintd pmi!lt melevations of strum trans;)millilst~ and prior hypt~nsitiY
ity to tht drug.
ADMINISTRATION ALERTS
Administer with food to de<rtasr GI discomfort
M.y Ill' takrn at .n, tillll' of tht day.
PrtgnallQ calfgOl)' X
PHARMACOKINETICS
Onset: 2wk
~k: Pblllu wllcl'nmtion, 1-2 h;(holl'stl'lOl reduaion,2-4 v.it
Hillflife: 14 h(20-10 h for aail'l' metJboiit61
DUlmon: Unknown
INTERACTIONS
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22.7 Pharmacotherapy
with Nicotinic Acid
Nicotinic acid, or niacin, isa B-complex vitamin. Its abiJityto
lower lipid levels, however, is unrelated to its role as a vitamin
because much higher dose:sare needed to produce its antilipidemic effects. For lowering cholesterol, the usual dose of
niacin is 2 to 3 g/day. When taken as a vitamin, the dose isonly
25 mg/day. The primary effect of nicotinic acid is to decrease
V I .01. level., ~nd h"""n.e T.m. i. <ynthe<ized fTOm VI.oI. The
patient experiences a reduction in LOL levels. It ~Jso has the
desintble effects of reducing triglycerides and increasing H OL
levels. As with other lipid-lowering drugs, maximum therapeutic effects may take a month or longer to achieve.
Although effective at reducing LOL levels by as much as
20%, nicotinic ~cid produces a higher incidence of adverse
effects than the statim. Rushing and hot flashes occur in almost every patient. In addition, a variety of lUlcomfortable
intestinal effects such as nausea, excess gas, and diarrhea are
commonly reported. More serious adveJW effects such as hepatotoxicityand gout are possible. Niacin is not usually prescribed for patients with diabetes mellitus, because the drug
can ntise fasting blood glucose levels. Because of these adverse effects, nicotinic acid is most often used in lower doses
in combination with a stalin or bile acid-binding agent. Taking one aspirin tablet 30 minutes priorto niacin administnttion can reduce lUlcomfortable flushing in many patients.
CIlo",0112
~ Prototype Drug
211 1
Cholestyramlne (Ouestran)
PharmacologicClass: Bileacidresin
INTERACTIONS
re.:allo~.
ADMINISTRATION ALERTS
Mix thorooghly with liquid and hom the pam,m drink it immedia~ to
aYOid potential irritation orobstruction in the GI trac:t.
GiW' other drugs mort than 2 hoors befOIl' or 4 hours aner the patitm
takes choil"ltyramine.
Pregn,IIICY Ultgory C
PHARMACOKINETICS
Onset: 24-48 h
I'Nk: 1- 3 wIc
Half fife: Unknown
~:Hwk
ADVERSE EFFECTS
Although dlOlIosryramillt rall'ly produces worious sKIt effeds, poatitnts may ellptritn~constipation. bloating. ljaI"nd nauwoa thit wm!'ti~ limit its UW'.
Contraindi m ions:Th is drug is cOllm indic:.Jted in patitnn with toLlI bilial)' obstruction and in th<M with prior hYpl'lII'nsitivity to the drug.
Becawe niacin is available without a prescription, patients should be instrucled nOI to attempt self-medication
with this drug. One form of niacin available OTC as a vitamin supplement called nicotinamide has no lipid-lowering
effects. Patients should be informed that if nicotinic acid is
to be used to lower cholesterol, it should be done under
medical supervision.
OIIeopolfWi.
lINI ment of Oerdosr: Theil' is no sptcilic tft'aimem for ~rdose.
IIrfl'l III M)NUIlInqm for Q NlmllJl} I'n:ms foaII Jjlf(1k III rIr/s ~
22.8 Pharmacotherapy
with Fibric Acid Agents
The first fibric acid agent, clofibrate (Atromid-S), was
widely prescribed until a 1978 study determined that it did
nOI reduce mortality from cardiovascular disease. In fact,
clofibrale was found to increase overall mortality compared
with a control group. Although clofibrate is now rarely prescribed, other fibric acid agents, fenofibrate (Tricor),
fenofibric acid (Triplix), and gemfibrozil (Lopid), are sometimes indicated for patients with excessive triglyceride and
VLDL levels. They are preferred drugs for treating severe hypertriglyceridemia. Combining a fibri<: acid agent with a
slalin resulls in greater decreases in triglyceride levels than
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Tht nUlle ,dministm tilt following 0,,1 medic:.Jtions orderrd for , 64-~a r
old man: tetrac:ydine SOO mg bid, digoxin (l.iooxin) 0.25 mgfrby, and
(holl"ltyramine (1)JI"ltran). g bid" ,nd at bed time. At 8:00 '.m. befm
bll'akfan, W nulII' administflS tM"()'I:lillt SOO mg..digoxin 015 mg. and
choll"ltyramine 4 mg. 'Mlat shooklthe nulII' haW' dollt diffmntly?
StrAppmd/lDfIIIlht JlM]qeIItd_
292
..
Prototype Drug
Gemfibrozil (Loptd)
ADVERSE EFFECTS
Gtmfibrozil produc6 fM Iffious ad~ etrfcts, but it may inul'iIse tht li~lihood ofgalillonesand mayomsionally . ffect Irmfull(tion.The moll rommon
.J<Mtweffemalt GI rI'lated:dyspepsia,diarThe., na!M.J, and cramping.
Contraindication!: GtmfibrOlil is conmindic.ittd in patienn with hepatic impairmen~ II'~ It It llil dysfunaion, 01 plt-e. isting gallbladder dist.II', or thOl!'
with prior hypellfMitiYity to the drug.
INTERACTIONS
l)ug-DIII!I: ColKllllllt w 0( IjfII1fibroli with oral anticoago..tln6 may pOl!ntidte
PrI'gnalK1 categolY B
PHARMACOKINETICS
DnSft: 1- 2 h
PNk: 1-2h
Halflife: I.S h
DUlation: l-4 months
dcfllii1anliiabeticigl'OO.!IaIin!,~andVtamin Kmgoom.
IfIIIn ~ Iewls.May
When given as mono therapy, ezetimibe produces a modest reduction in LD L of about 20%. Adding a statin to the
therapeutic regimen reduces LDL by an additional 15% to
20%. Vytorin is a oom bination tablet containing fored-dose
Assessment
Bilst line aSHssment prior to administration:
Understand the Itilsan the dlug has betn Prl'lcribe<i in order 10 a!1f"SI for
therapeutic tifects.
Obtain a{omplete heakh histolY including cardmaKular,mU\{\JIos~1m1
(prt-existing (onditions that might rl'lUk in musclt or joinl pain).
ga>lrointeslinal (peptic uk~ dill'.J ~, hMIonboids, inllammalOlY bowel
disNse, chronic constipation, dysphilgi. or tIOphageilmiclUltS), and the
pos~bilityof prtgnalK1.0btain a drug histo!), including alltrgits,culR'm
pl~cription .nd OTC drugs. heib.1 prrpal~tion~and il kohol!M. ~ alen to
pos~blt drug intefactiom..
[nwte .ppropriate laboratolY finding~esptCiill~ li~ fUnction studits
and lipid profilts.
~I( th~ patiem's ability tQ lciYe and ullwmand inltruclion.lndude
family and cartgiYeIS as nredtd.
Asstllment throughout administration:
fol desiltd therapeutic effu (r.g., M~ total cho~eroI,lDl
It~k. in{lI'iIsed HDlIt~~).
CominUf periodic monitoring of lipid plOfiirs, liYef function lIudits, CPK
(UI'atine phosphol:illiSt), and uric acid ItYeis.
~Iffi for advet1t tlftm: mUl(ulosktieul dist:omfort naUSl'~, vomiling,
abdominal Clamping. diil rrhN. Se\'ffe muswloske\etal pa in. unexplained
muscle tendmiessaccompanied by fto~,inabilil)' to maintain activities of
diily liYing (ADls) die 10 musrulosktlttal wt'akness 01 pain, unaplained
numbnesl; or tingling of eXlrl'mities, yellowing of KItI.J or sl:in, ~
constipation, or straining with passing of lIook 01 tarry stools shoold be
It'pOrted immediattly.
~Iffi
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(1101'1" 12
293
ExptritlKf t~raptUlic: flfects kg.,lowt-rtd total choottroU(l, illUNltd HDI., oormall~r ~nzym~).
or ~lptritlKe mioim'~ idv~B!' ~if1S.
V~rbal~ '0 uodtrst,nding olt~drug'. 1M, ,dv~B!' fifb, aod rrqJi~ prruutiom.
o ~ ~ from,
o
Demonmat~
(Conrlnued)
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294
Evaluate the tffM~ntll of dn.w,j thtrapy bJ(onfirming thlt patifnt goiIls Ind tllpf(ltd out(/)"'" hatt btt n me{ (Sft1'LlnniIMjl1.
Str Ii/.IIt III frz. fit iii dru" l~ II'IIt1I rlltst IIniI9 tdionI"
effect.
u') Blood IIpk! protl1e!i are Imponam diagnostIc tools In
guiding the therapy of dyslipidt'mias. Theoptimum levels
of the different lipids are reviewed periodically and ad justed based on the results of current researcl! .
22A Before Marting pharmacotherapy for hyperlipidemia, pa tients shouJd seek to control the condi tion through
lifestyle changessudi as restriction of dietary saturated fats
and cholesterol. increased exercise, and smoking cessation.
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effedi~
for most patients and are drugs of choice in reducing blood lipid levels.
22.6 The bile add resins bind bile and cholesterol and aa:elerate Iheir eu:retion. These agents can reduce cholesterol
and IDL levels but are not drugs of choictdue to their frequenladve~eff~
'lIop"< 12
295
Th .. nurse assesses the patient on a stalin drug (HMGCoA reductase inhibitor) for.
I. constipation.
2. musd{'or joint pain.
3. hemorrhoids.
4. flushing or "hot flash."
II
When evaluating the efflivmes.s of lipid -lowering ther apy, the nurse would monitor for:
1. increased total cholesterol, LDL,and HDL te.-els.
2. increased LDL lew:lsand decll'ased HDL lewis.
3. decreased total cholesterol and LDL lewis, and increased
HDLlt'wls.
4. maintE'naoreof cholestero~ HDL,and LDL [{'WI&.
II
1:1
The nurse is instructing a patient on home use of oioolink add and will indude important
jnMru~ljon'
on how
to take the drug. The nurst' will teach the p.1tient to:
1. take the drug an hour before mm and with plenty of
~"'.
2. mix th .. drug thoroughly in watt>r before taking.
3. A male dtabettc pattent presents to the emergency depart ment with complaints of being flushed and having "hot
flashes.~ The patient admits to self-medicating with niacin
for el,,'V:lled lipids. What is the nu='s response!
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EXPLORE
~.-----,
is yoor ooe SlOp for online CIl apler Il!'llew materialS 3f1d
reooorCOls. PlUl/are b IiUCCUSS IMtIl ad~ilional t~st)le practice
Quesliln3, Interacti\'e 8S3ilJlVllenl'l Bnd al:lNitie3, web tirK'l . IIllrmtlons
and ~jjeos. and mete!
M~rsing llJl
DRUGS AT A GLANCE
DIURETICS
pqJal
....
LEARNING OUTCOMES
,.4
p.1JtJ()7
Inhibitors ".NI
Q enalaprt/ (VaWl) {lQ)tJ!]
Bet.,AdreMl9i(BkdtfS
ptJIJtJU
Alph.rAdlftltfgkApists ptJtJtJI5
KEY TERMS
pu;tJI~
ffftu tamycudia
ugiotenlin II rx;gtJIO
u giotfmiNOII'Itfting t nlynlf (ACl) (II1IJt J10
Intidiumichonnoe{ADH)
strokt wkJ:nt
yu0ll10l0f(tnltr pogt]!;8
(i09t199
llIrtnplon (II1IJtXA
GJkill'JdlanMlbIoxur{(CB) pogtXJl
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ffnin-lI1gio~njHdojwont Iyst~m pq M
Sf(Oft darJ~yptrltnlion rgI199
ptJ//I198
297
TABLE 23 1
Statistics of Hypertension
Prm1Pfl"tmsion (120-1391BO-89 mmHg) alfts .Jpproximately 22% of
till' adult population,or IJNrfy 4S million ~plf.
High blood prt'IUJ~ alfts mo~ thin n million U.S ..J<kJIu,o.approlimateiy 0111' in thrt'e Americans.
African American malts h.Je the highest rate (SI"') ofltyperterllion.
Among ~ple with HTN, mOrt' than 28% do not INlize IhI')o h~Y!' the
mndilion.
Hypertension is t~ most common compliution of prt'9ni1ncy.
Approximately S4,000 Americ~nsdie of HTN per year, it isa contributing
facto.- in 300,000 additional duths e~dJ yw.
-,
119!79orlfll
No inlihypentnsil'e indiuttd
Hoantihypertrnsiw inlicattd
~ypertension
1ll}-B9ft11)-!I'}
l.fO-1591W-99
I Hypertension
5tagf 2 Hypenension
Souin': Halionitl H91 Blood ~1!u1I' EdlKation Progr~m Hationaillein, l.ung& Blood Inst~ute.11O(3)JIK-7 &preIl:Thf Smnrh/Wpilrl rile mil NariiJooIfilmmirlet m
I'rPM1nD'on, Dtlfflion, fllWaion, ~I1fJrrel!l!ntJJI liqh Blood I'rmIJrt. Ioo-ine1hnp://Www.nltlbiJlil.1jO'>'
"Compelilg indK.Jtions i1dude:hein fallft, post....... youlllial infirnion, h9I rill:: for roronary .Jn~ dise~~, diabflfl, dlrorK kid!le)' dst.t\e, ind Murrtnt stroiIl' P'"tnlion
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o
o
i"
iI!
"
!
Peripheral resistanoIw'
diameI"r of .rterioles
AJid Ioao
Det.;<lration
AJid mlen1ion
Aldoote.one
' .<OH
Symplllhetic fl81'VOU11
'YI',. m activity
Rerin/angio1ansin II
t...,..IM in blood
""""";Iy
Cwliac
ouIpUI
P""OIIo;!
eomractiity
. ~rlOlld
-Heart ...
- SI"""'IheIic ..."....
.,..-
.---.ya. . .
_ ~1helic
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01",1<,23 DN9,forHYI"'nemlon
299
Blood pl9DUno
C<lmp"IISatory action by
r:ar<tkMIscuta'system
i
Vaoodlaaon
Flgure23.2
Because chronic HTN may produce no identifiable symptoms, many people are not aware of their condition. Failure
to control this condition, however, can result in serious consequences. Four target organs are most often affected by
prolonged or improperly controlled HTN: the heart, brain,
=-
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23.S Nonpharmacologic
Management of Hypertension
When a patient is first diagnosed with HrN, a comprehensive
medical history is necessary to determine whether the disease
can be controUed without the use of drugs. Therapeutic
1 00
UnII4
Va somotor cent",
in medul a
Angiot&nsin II
Qung"J
Angiotensin I
Qi""'J
""
8aromceptors
j
'" Vasoconstriction
Chang .... in
e '" Vasodilllion
I~id
vol ........
;<
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01 ..11.,23 Oru9,lorHyperten,k>n
as stroke and heart failure. Severnl stratt'gies that are used to
achieve this goal are summarized in Pharmaoothernpy Illustrated 23.1.
The pharmacologic management of hypertension is individualized to the p.1tient's risk factors, comorbid medical
conditions, and degree of blood pressure elevation. Patient
responses to antihypertt'nsive medications vary widely
because of the many complex gt'netic and environmt'ntal
factors affecting blo<Xl pressure. A largt' number of antihypertensive drugs are availablt', and choice of therapy is
often based on the experience of the clinician. Although
antihypertensivt' treatmt'nt varies, there are several principles that guide pharmacotherapy.
In mosl cases, low doses of the initial drug are prescribed
and the patient is re-evaluated, after an appropriate time interval.lf necessary, dosage is adjusted to maintain optimum
blood pressure. The following drug classes art' considered
primary antihypertensive agents:
- Diuretics
Angiotensin -converting enzymt' (ACE) inhibitors
Angiotensin II rt'ceptor blockers
PHARMACOTHERAPY ILLUSTRATED
23,1 Mechanism of Action of Antihypertensive Drugs
Atpha 2 agoni
cllUaing vBsodilillion
vem lEllion
D iroot
.Ieri""'.,
......,.., of
causng vaoodil9lion
Calcium channel
nodJc:ing cattliac
blocker.
Block calcu m ion
c han",,11 in arterial
smooth mU!ICle.
ca"';ng
vaoodilalion
~""'
Angiotenain
receptor bloc k...
~~
'1
_ _
ACE inhibilor.
Oiurem.
Incnoase ume output..::l
doocnIau Huid voklme
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301
302
Beta-adrenergic antagonists
Calcium channel blockers
The JNC-7 report recommends thiazide diuretics as the
initial drugs for mild to moderate HTN. Patients with a
compelling condition, however, may benefit from a second
drug, either in combi nation with the diuretic or in place of
the diuretic. The JNC-7 report lists the following ~s com_
pelling conditions: heart failure, post- myocardial infarction, high risk for coronary artery disease, diabetes, chronic
kidney disease, and recurrent stroke prevention.
Prescribing two antihypertellSives concurrently results in
additive or synergistic blood pressure reduction, and is
common practice when managing resistant HTN. This is often necessary when the patient has not responded to the initial medication, has a compelling rondition, or has very
high, sustained blood pressure. The advantage of using two
drugs is that lower doses of each may be used, resulting in
fewer side effects and better patiem adherence to therapy.
~11~"('
~ '~(~[~dury r~
Thiazide Diuretic
Ao:rurtiK
hyd rodKIrothiazidt
Aldactillidt
hyd rodKIrothiazidt
AVoilidt
hyd rodKIrothiazidt
""
BtniurHCT
hydrodKlrothiazidt
"-
Adrelll'rgic
Agent
........
hydrodKlrothiazidt
bmdroll_liaridt
"-
~ov.lOlfCT
hyd rodKIrothiazidt
hyd rodKIrothiazidt
H. .,
hyd riXtlorothiazidt
Indtridt
hydrod"lorothiazidt
qunapril
irbNrloln
.-""
hydrod"lorothiazidt
(,Jptopril
IIIls.Jrlolo
uiolmltrtne
voIls.Jrloln
hyd rodKIrothiazidt
"".
T....
...,
.-
m!iolpril
btOilepriI
oImlodipO!
VrloI()oInil
....
TemffilfCT
hydrodKlrothiazidt
Iimolidt
hyd rod"Iorothiazidt
Uoi'tiK
hyd rod"Iorothiazidt
rnouipril
VilItlffK
hydrod"lorothiazidt
m!iolpril
l!-!torttK
hydrod"lorothiazidt
'"
hydrod"lorothiazidt
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fmjpiO!
trolodobpril
hyd rod"Iorothiazidt
hyd rodKIrothiazidt
oImlodipO!
bmaztpril
TeWIN IfCT
dllonllal~
oImlodipO!
IoIartoin
_~HC1
lotftllin HCT
m..,
oIm~l1iIo
Dyazid/,
"D.
ACE Inhibitor or
Angiotensin II Blocker
oIm~l1iIo
"""'
PotassJum-spa ring
Diuretic
oImilorid/,
_ru"
timolol
.......
Iililopril
~m_
"'... lfr 21
303
with Diuretics
Diuretics were the first widely prescribed drug class used to
treat hypertension in the 1950s. Despite many advances in
pharmacotht'rapy, diuretics are still considered first-line
drugs for this disease because they produce few adverse effects and are very effective at controUing mild to moderate
hypertension. In addition, clinical research has clearly
demonstrated that thiazide diuretics reduce HTN-related
morbidity and mortality. Although sometimes used alone,
they are frequently prescribed with drugs from olher antihypertensive classes to enhance their effectiveness. Diuretics are
also used to treat heart failure {ch.1pter 2400}and kidney disorders (chapter 3QOO) . Doses for these agents are listed in
Table 23.3.
Although JlIany different diuretics are available for
HTN, aU produce a similar outcome: the reduction of
",,'
Adverse Effects
POTASSIUM-SPARING DIURETICS
0Ilffi'1MfiII (spirmollKloot)
triamll'rfllf (o,rmium)
amiloridt 1Midamofl
tpitlt'llOllf(lnspr.l)
Minorhyplll"dtrnio,. fotiglll'
dKinhalidont (H)'I)1Itonl
Sianifi@nlhypoblellia,*<trolmdepk!ion
dehl:l!al!!m, !ral!l!l'n~on, maUmlia
hyperdrumia roma blood dyxmia1
IrfdrodKlrothialidt (Mirrozidt)
indapamidt (loroI)
methydotliuide(Endnm)
metol.JlOIII' (Zarmolyn)
LOOP/HIGH-CEILING DIURETICS
btmti,nidt (BlIIlfl)
toBtmidt (Dtmadtx)
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304
The primary concern when using potassium-sparing diuretics is the possibility of retaining too much potassium.
Taking potassium supplements with potassiwn-sparing diuretics may result in dangerously high potassium levels in
the blood (hyperkalemia) and lead to cardiac conduction
abnormalities. Concurrent use with an ACE inhibitor or
angiotensin II receptor blocker significantly increases the
potential for the development of hyperkalemia. Spironolactont' (Aldactont') is featured as a prototype drug for this
class in chapter 3000 .
Tht' loop diuretics cause greater diuresis, and thus a
greater reduction in blood pressure, than the thiazides or
potassium-sparing diuretics. Although this makes them
very effective at reducing blood pressure, they are not ideal
agents for HTN maintenance therapy. The risk of adverse effects such as hypokalemia and dehydration is greatt'r because of their ability to remove large amounts of fluid from
the body in a short time period. Loop diuretics are also ototoxic and may cause deafness. Because they have a higher
potential for toxicity, loop diuretics are often reserved for
more serious cases of HTN. Furosemide is the only loop diuretic in widespread use, and it is presented as a prototype
for heart failure in chapter 2400.
I Hydrochlorothiazide (Mlcrozlde)
ADVERSE EFFECTS
tms_ giIomrih
~~QIMd"~IIW)'int:ffD~in
todtJHydrodiIorothia dKruststhPmretionoflhilrn iIId(;ll\ Nlto~
PHARMACOKINETICS
il'lset: l h
Pe.k: ~ h
Half~ife:4 S-120
min
Dur.tion: 6- 12h
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305
Assessme nt
Dmcient FluidVoume
Fatigue
Dffit'ased CardioK Output (R'lattd to a.m~tflecB of diurflics)
Dtfitient Knowledge (drug thmp)')
Risk for Falls,Rilk for Injury (R'lattd to hypoltnsion,diuinesl allO(iall'd with
adw"SI'effb)
Risk for FulKtiona IllKOOlinl'lKr (R'lattd to diull'tic: USI')
Risk for NolKomplialKf (reI.itrd to Idve~ effb of drug thtrap)')
BPJ.
patiem will:
U:ptrielK~ llitrapMic: effb dl'Pffidtnt on the rtawn the th~ drug is being giml (i.f.,de<R'aseci blood PIl'SIUIl').
~ fret from,or ~lpl'rielKe minimal, idw"Sl' ~ffts.
V~rbal~ an undtr>,andiog ohhedrug'1 USI',ldYl'~ flfb, and R'qJired pll'lautions.
DMIOnltrat~ pflllll'l" :self-administration oftht medication k9.,~ timing, wht n to notil)' providtr).
Impl e me ntati o n
Interve ntion s and (Rati o nale s)
Ensuring thrrilpeut k effects:
Continue frequent iIIlffimerllS ill aboY!' for theraptUtic: tlfb: blood
presruR' ind puisI' are within norllYllimil>orwithin parametm 11'1 u,.
lilt lItakh {ilR' provider. (Systolic: and dystolic: should Il'tum gridually to
nomullimits without lilt p!I'IfIl{e of reflex tac:hlUrdia.)
Daily wtights should remain at or dOlI' to billl'linewtighl (An in{ft'~ in
Wfight ~ 1kg pl'rday may indic:.Jtt fll(flSiYf fluid ljiIin.A dt{re~ of
Offr 1kg perday may indicatf !j[(esi'll'diuresis and dthydration.)
Ttaoc:h tilt paDl'nt to risf 40wIy from lying or litting to standing to avoid
diuint lS or falls.
InstnK1the patient to stop taking the m~dic:.Jtion ijblood pR'lsure is
90/60 mmHg or btlow, or param~tm 11'1 II)' the hulth cart proYider,ind
ootil)' th~ prwider prompt~.
(ConrlnuefiJ
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LItxntorypm.onneloliUtKtberapywhM~l'WIbIoodOlm~.
EnWft
ilal't the pltitnl.,mgh Iflfdaily, idfally II the Sime timeof da,;and it(ord
wtighl.long with hlood p!t1SOlt Ind fIIlIst meiHU~ts.H.1't the patitnt
I!port wtight 1011 or9iin of molt than 1kg in iI 24-hour period.
Advise lilt poatitftt to (ontillur 10consume mougb ijquids to rtmain
~e/y, but nol 0e!Iy hydrJled.. DrNil'Wl wlw:n 1~1)",<l"fOicling akoholK
~,and fIIwring .dt~l~ but IIOlutflsi\'t wit inuktwill assisl in
mlint.aining normallkJid bal.lnct.
kId! tht pllitnt tlloll b"CHsiYt hflt condilions comribute 10tIKtlsm
swming, ilnd It.Jid ;md electrolyte loss ilnd tbil b"tril QUlion is warr;mted ill
thelf(Onditio!ls.
palitftl IiIlrty,epf<i.lly "1hf~.Obsfl"ft' for lighthudtdnes Of dizzines. Monitor Imbulation until effemofdrug a~
known. (Dizziness from orthomtK hypottll'lion m.ly 0((\11.)
Inslruct ~itnu liking potusiumwmrilgdiurttics (e.g., thilzidts,tbiaziclelikt,and loop diurtlial \1:1 (omumf foods high in potusium:frtsh!ruits such
as stfJWbtrrie.nd bananas;dried !ruiU such <II apricon and pn.rot\;
lfI!'gtI.bln and ~ suchas tomoJIOf'l, bettS,ind dritd bUns;jUKtI such
as or;m9f,C]I"apl'iruit 01' pru~ and fifth mNIs.
lmllllCl p.llifms tlking pJtisslirn-splrirg di.RtiG 10 mil iXKk ~h iI
potassirm such .s aboYt, nol \1:1 USf Ilk suktitultl (whKh oftrft (OfI1lin
potassirm lilts), ind 10 ClHIIUh with iI Ilulth ore p!OYider !rill! taking
tiumill and mineral~s Of specialized sports btI'tr<l9fl.CTypOI arc
sports ~t.I}-,Gamrldf and Pa.l'trilk,mayhaw lelff amounh d
pJmWm but hal't high{aJboh)dnle amoo..IU th.Jt rna, Iud 10 M.stc:i
diJrei!, diarrhea. . nd pote"IIiiI for dt/tydriltion lrom lilt h)'pI'IOsmoiarityJ
'If
Instrud the pltirnl \1:1 Jfporl .ny It.J!ikt symOfM:Shor!neS 01 hl!iIIh, !Mr,
sort throa~ rMLIise,joint pain,or prolound latigur.
Tht pltirnt anNorw~im- shouk! bt i1ble to stall! lilt rtasort lor lilt drug,
and i1PJ1ropiate dose and IClleduling;what iJ6.otlSt tfftc:ts 10 obstrvt lor and
wbe!l1O rtport ilnd tht ilnticipattdlength of mtdiutillfl tMrapy.
306
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OUplfr21 Dru9,/orHypellemkln
307
ihtrap, by oonfinning that pititm gNkand txpKted oukom~, hnl' bffil ml't (Sle PlanninifJ.
Str TIIbIt 111 for Q 1stIi/hili to wIidr rIleit IIIrlill) 1ilnI gppIy.
23 .9 Treating Hypertension
with ACE Inhibit ors and Angiotensin
Receptor Blockers
The renin-angiotensin-aldosterone system (RAAS) is one
of the primary homeostatic mechanisms controlling blood
pressure and tluid balance in the body. This mechanism is
ftlodpilt (Plmdl)
i>radipineIDynoCirc)
riurdpjne(C.udtn~j
rilOldipine (ti5O(0I'")
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rOlJJfirlorionJarigue, wtt1knru,myrr1~,
~1/rQlI}Io.lrrrpolerta.md5tllJlJ! dyWrlflion
10 8
Do not admin:nl'l imm~dYte-I'I'Ie.m formulations of nifedipinr il an impendi09 MI iSlUspeued,.or within 2 Wftks followi09 ,I confirmed MI.
Administer ni~dipiOl' "psules or ublets w~.1f upsuies or utmded1l'Ie.IIt ublw all' c~divided, or rMhed, t~ rmirr dolt will bedrli"l'!'ll'datonu.
Pll'9 o. nqrattgoryC
with rifedipilll' III blood /lll'=r. Coooi"rmt!llt of n~piIe with ,I lieu bIcIcRr
inm.N'i 1M rill; of COO(j@Sti"lthtartfaln.NlediplII'lIIa1l1mNserumlt"ltl.of
!igolin.leadilg to bradycardia and digoxin toxicit~.I.lcohoI polflfioll!l ~
mDlilati"9 action of n~piIe. and cook! lead to 'Y1K1Ipf taM by a_drop
inbloodpll'l.lUJI'.
~1k:30min
Hall~ile:2 -5h
I1tI'8" 111 MyMIsIniJU fix a MnJnq 1'rIxt55 fooIl 'ipK/It 1II1M It!!g.
Assessment
Bistline aSSf!!mrnt pri or to admini,tration:
Undtrstand t~rt'50n the drug ha, bten pll'SUibed in orck-r to aslfSS for
theraPfUtic tfuru.
Obtain a compietf heakh hillory includi 09 cardia<. se:ular (including MI. hean
failull'), mUl{Uloskfleta1 (pft'~uning condition, that mightll'lUk in fatigue,
....,.,Iknffi.IIIJ!C1e or joint ".in), and the possibili!)'of pft'gn'nq.Obuin. drug
h~lor1 illwdinj .Ilrfljin.w".nll"..... ,ipliun .lId OK d,IIIJ',I"''''''
pr~"atiolll,,,d akohol UH'.8e ,lien 10 possible drug intmction,.
E'lilwtf appropriate laboralOry findin95.Mctrolytts,~ially potmum 1M,
I~, fulKtion ru:lie~ and lipid profile.
Obtain baH'li~'Migh~ fiul sign, (espe<ylly BP and pullf), brNth lOUnds.and
"n:!iac monitoring (t.g. ECG.ca,diac output) if ,Ippropriate.AsIfSS for Ioution
.nd charactf" .nount of rdtma, if f'Il'H'nt.
Assf,sment thlllugh out administration:
AsH'15 klr desirtd therapeutic NitcU (r.g.,1owt1l'd blood f'Il"lUll' within
~,t.blished limit!;; .150 less~ord or ,Ibll'llt ' 09ina.nd dysrilythmys if pll'll'l\t).
Cominue periodic monitori09 of Mctro/ytts,especilily potassium.
AsIfSS klr adl'el"!l' rffrm: n,IUII'a. huda(~. (orutipation. mUlculoskflrtal
fatigue or wukrll5~ fWI iog.. diuinffi. or smwl dysfunction. Myalgia,
,Inhralgia. perip/ll'lal or lacy I~dtma, signifium con,tipation, in,bility to
maintain ADu M to mUl{Uloskfleta1 wukOl'l5 or pain .J nd unapla iOl'd
numbllffi or tingli09 of utll'mities should bt Il'ported im miatfly to the
hNhh caft' prmic!et
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INTERACTIONS
I)ug- l)ug: ~ giml cOIICurrently.1IIhH ,Inlil)"pfnflllie\ haonadlitftrifm
lab Tl5ts: M.l\r lImN vakIeI for tilt foIowill9lab tfllS: ,IlaIn p/IoIphalMt,lDH.
ALT.cPK,and ,1ST.
PHARMACOKINETICS
il1..t: 10010min PO
ADVERSE EFFECTS
~JW rffrru of nifedipiOl' all' grnerally minor and all' Il'I.trd 10 nsodilalion
IlKh a, hudar~diuiOl'Ss, periphml edema, and Au,hing.lmnrdYte-arti09
forms of niled ipiOl' "n ralJW Il'IIeJ urhyurdia. To avoid I'I'bound hypotension,
thedrug should btdisc:ontinued gradually.ln rall'ulfS.nifedipilr m.ycauH'.J
pmdoJiiul inrll'asr in a09io.l ".io, possibly II'Iated to hypltmsion or heart
lailull'.
Contraindications: T~ only contraindication is prior hype!>l'OsitWity to
nifedipiOl'.
OUplfr21 Oru9,/orHypellemkln
309
Mon~or for signs of Ile~n t.I ii.Jft', wch as ilK~~ ling dysPIIN or posrural
Te.Kh thr pat~nt or family how to monitor pulsr and blood pressurt.
Ensull' p~ Ul!' and fulKtioning of all)' homr ftIuiPllll'llt obuined
"G<
Hm thr patirnt weigh selfdaily, ~ally at thr sallll' timt of day, ind
ft'(oro wtight along with blood pIl'IlUll' ind pulst mtilUft'mtml .
Hm thr patirnt report ~ight 1011 or gain of moll' than 1 kg in a 24hour ptriod.
Inluu thr patimt to immrdiately repln (htlt pain or other angirulil<t I)Imptoml, tspttially if symptoml inaeal!'.
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310
illustrated in ~ Figure 23.4. Drugs that affect the RAAS decrease blood pressure and increase urine volume. They are
widely used in t he pharmacotherapy of HTN, heart failure,
and MI. Doses for these drugs are listed in Table 23.5
Renin is an enzyme secreted by specialized cells in the kid ney when blood pressure falls, or when there is a decrease in
Na+ flowing through the kidney tubules. Once in the blood,
renin converts the inactive liver protein angiotensinogen to
angiotf.'rnin I. When it passes through the lungs, angiotensin I
is converted to angiotensin II, one of the most potent natural
vasoconstrictors known. The enzyme responsible for the final step in this system is angiotensin {onn rting rnzymr (ACE). The
intense vasoconstriction of arterioles caused by angiotensin
II raises blooo p ressure by increasing peripheral resistance.
Angiotensin II also stimulates the secretion of al oosterone,
a hormone from the adrenal cortex. T he primary action of
aldosterone is to increase sooium ion reabsorption in the
kidney. The enhanced sodiwn reabsorption causes the booy
to retain water, increasing blood volume and raising blood
pr.....~"re. Th,,~, ~nginten.<in " inc,"""",_< hlnncl pre<.~"r"
through two distinct mechanisms: direct vasoconstriction
and increased water retention.
First detected in the venom of pit vipers in the 1960:s,ACE
inhibitors have been approved for HTN since the 1980:s.
Since then, drugs in this class have become key agent s in the
treatment of HT N. ACE inhibitors block the effects of angiotensin II, decreasing blood pressure through two mecha nisms: lowering peripheral resistance and decreasing blood
volume. ACE inhibitors enhance the effects of the t hiazide
diuretics; thus, drugs from these two classes are oft... n used
concurrently in the management of HT N. Some ACE in hibitors have become primary drugs for the treatment of
heart failure and myocardial infarction, as discussed in
chapters 24 and 2700 , respectively.
AdverSt' effects of ACE inhibitors are usually minor and
include persistent cough and postural hypotension, particularly following the first few doses of the drug. A persistent,
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Increas.&d oodium
reabsorplion
I"",,,,,sed blood
p",""re
0I ..1I0I2l
ON9,lorliype"""1on
3 11
TABLE lJ.S I ACE Inhibitors and Angiotlmsin II RC!cC!ptor BlockC!rs for HypC!rtC!nsion
Route and Adult Dose (max dose where Indicated)
On"
Adverse Effects
ACE INHIBITORS
~gle 0:IIt or dvidtd Oul (nw:40 mg/day)
bffiaztplil (loteosin)
PO; 111-40 mg in i
uptopril(upo!m)
/rtpolt1llkl\.raJli
PO; 540 mg in i
ffiilapil (If.HotK)
~gle!be
tosinopri (Mooopril)
(~~
mmipril(Uri'loJI()
ptrinOOpn (Aaon)
quinapril (Aaupril)
l'irripril (AIt"tj
U"indolipril (Malik)
Undl'Sirtan (Auc.Joo)
~Sirtin
(kI!trn)
irWSirtin (Al'ipro)
Ios.Jrtin ((Olia')
PO; 25- 50 mg in i
oIm~rlin(Btnicar)
telmiSirtin (Mkartil)
nlSirtin (Oiovin)
--c-~---c-
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Management of Hypertension
in African Americans
~ incidfnct of 11TH is lignifiuntl)' higher in AfrKan Americam than i1 OIl1fr tth-
nit grtt.pS. As expKted from this high imnet, Nri:in Amtrium operiera
grHltI" ufget-Of9iIn damage than other populations. In in effort to ~~ the
high morbidity ind mortiIity, i991NM- ~ntih)1ltrtensM- thmp)o rna)' be IIf(e5Sir)' iDOrKOIIII' r!Si!tant H1N i1 AfrKan Amtriuns.
Studits h.M SuggestN thilt [Main intill)'pffl~nsjy~ drug dillts are 1m
tffIoctiYe in Afric.i nAm~riuns. For 6IImpit monotheriPY with ACE inh ibiton,
ingiot~nsin II f"r(tptor bIocktrs Of bm-adrtnergit inligoni!ll dots Mtl!duct blood prt'Iwrt islllKh in African American~ [Omp.lrN to otlier ethnic
groups. Som~ physiciim f"r(ommeod initiatingthffilpy with two drugs to ~n
wre i!lequatt ~ponll'.Bised on dinicaltrials in African American~ th~ FDAipp~~d BiOi!. i fillfd--doSl' [Ombinition of isosorbide dinitrm ind
hydrilazine thit ippHri 10 be p.lrtKularf)o ~ffffiMo at lowering blood pressure
in this population.
31 2
I Enalapril (Vasotec)
ADVERSE EFFECTS
Uni~ diJretKs, ACE inhibitors wch <II fnalapril havt little tlFta on . IKIrolytt
b.lalK. but may (')u1I' hyptibltmia. Unli~ btu--adrentrgic blockers, tht ACE
ilhibitors (.I1JIt few o:ardiic advmt clItcts. En.lapril ma, ratJll' orthostatic h,pension when tho! p~tiem mows quickly fmm a supine to an upright position.
Ar. pid fall in blood pit!MIre may o(Qn bllowing the first dos . Otlltl oJdY!'rsuffem ildudt lIt. dirhe and dizziness. ACE inhibitors yn (.lUll' lift-lhll'aitlling
,mljotdtma, lI!'utropl'nia, or agla nuloqtoVs.
(ontrai nd irations: Ena Ia pril is {ontr. indicat.d in p.titnts with pOol hyptrsen~tivity and 5houid not bt <ldminislm<1 during pregnancy olla.:tuion.
INTERACTIONS
I)ug- l)ug: M-.n gWfn {Ofl(uJfill!ly,oIIwr antil)"pfrl~ hiwtadditN~flFfds
with fllilaprilon blood prI"I...... Thiazidf diulMiG ilKlMf po~~um loss.
PomsUn ~ or poIiI\sillll-spaOlIg dUtOO OOMl' Ihf riIlr:of
h)"p1::aIfnN.fnalapril rna, indua liIIIi..m tOIUy by rfduOlIg ~ d&Jraooo of
PHARMACOKINETICS
il"lset: I h PO; 15 min IV
J1ejk: 4-8hPO;4hlV
Half~ife: 2h
Assessment
Bistline asselSm.nt prior to administration:
Understand the re. lOn !he drug his been PlfI(ribN in ordtr to asst"lS for
thtrapMic: tfftcts.
Obt.in a (omplete lItakh hino" ilKluding {Irdia<u(ular (including M~ he. n
failurt), dia btt. s, rtnal dill'all',and the possibility of pregnillK)'. Obt. in a drug
histor, ilKk.oding .11e"lies,cuJTtM prel(ription ilnd OK drugr,htrbal
prepilatioJl!,.nd akollal ulI'.8. <l ltn to possiblt drug int. ractions.
E-I.1uatt .pprop nate laboratory findings, M Uo1)'1t!, t"lpt(ially potmiJm
~t li .. r fun<lion l1udies,. nd lipid p~r.1M.
Obt. in ~lineWfight, viulligns (flpt(ia l~ BP and pulse),brfillh sounds,ilnd
{Irdia.: monitoring (t.g. ECG,Yrdia( OUIput) if appropriate.AsII'II for the
location and (har-1C1erl.mooM of edem<l, if plI'II'nt
Assessment thro ughout administration:
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0I ..1I0I2l
ON9'/orliype"""1on
3 13
Ih~
p,titnt will:
Exptritnl:t tlltrlpMic: efferu k g.demalfd blood presSUII' to t sublished p'r,met~B).
Be ~ from, or uPfritrn minilN~ idww ~lffds.
V~rN)izt ,n undeBlanding olthtdrug's U1t"lt/efll' fIj.ts, and II'lJIill'd prruutions.
Demonsu,tr proptr ~-~dmioimation of!ht medication (t.g.,dose, timing. wh~n to notify providtr).
Implementation
Inte rve nti on s and (Rati o nales)
Ensuring th~r~peutic effects:
ContinUl' nqUl'nt aSSffitnents as d!<l(ribed Nrlitr for !htra pwtic: efflS.
(Blood plt'lSUII' and pu~ should bewithin oolTllilllimil5 orwithin j)ar;lmtltB
ill by lItakh (II!' providtt)
EO(oorlogt ,ppropriate lifrstylt [han91's. Prol'idt for dittitian (onsulmion "
nffil~. (Healthy lifrstylt m,n9l's willsuppon and minimizt the nffil for drug
thtrapy.J
Minimizing adft rse effKls:
ContinUl' to monitor vitalsigndake blood plt'lsure lying. ytting,and sl,nding
to dHe<t onhost,tic: hypottnsion. Be j)i nirula rly [,utious with the first frw
doses i nd with th~ eldtrly who,ll' it inc:rm~d risk for hypottMion.(MEIS i nd
ARBsuust modilation, resulting in IaMII'<I blood pressulI'.A signifium drop
in BP lNy oc:rur with the firstfew dom.Orthostatic hypotension IN)' inUNSt
tilt risk offalls and injJry.)
~ lilt patitm to anticij)itea dry COll9h that may ptBist Ind to lISt
oonpharmmliogic: measult'llo IlI'all~.g., OTC COll9h lozenge; or hird
c.od~, in"".>td Auid iot.~).
Instruct the j)ititm that iftlte(OII9h btc:omes troublesomt whrn in
supint position, sleep with tht head ~~ on additiOllilI pillows.
Advist the j)ititnt to (onsult with the health urI' plOl'ider about the
lISt of antihistamifll'S to reliev~ a prnistent (ough unll'litl'td by
oonpharmmilogi4: measul!"S.
Inl1ruct the j)ititm to report promptly any d\angt in the severity or
fll'qUI'IKY of alIJ9h. ArT; (ough oKrompanied by shonness ofbll'ith,
ltYer,or dltst j)iin should be II'pon~ immediately.
Instruct the j)ititm on the sigMof hyperulemia (nau..a, illl'9ular
lIt~rtbta~ profound fatig~/mUl(lewt~kness,and mw orfaint pu~)
and to II'pon themimm~iat~ly.
T~ac:h !ht patitm to avoid sak subsiilU!!1 [onuining potassium
[hloride (1((0, (onsuming snadn advtnMct is "I'learolytt-fonifltd,
sptcializtd spons drinln thit (onuin highftls of potauium,or
tl[rss~ inue offoods high in potmllmdifll'll'm from their normal
d"(LOnrlnued)
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314
UnII4
TheC.,dlOYOiscuIOl' 0100
Urinary Systeml
""ruoJ
Evaluation of Outcome Criteril
b.lu.netile ~Kliftne!1 oIdlll!l the!ilPY by COI'Ifirming mil P'litflt goak .nd ~lpt(Ird outOOme! h.m: ~n m~ (1ft'I'limning1.
StIr TalW liS /IHWr*AlJInNbi/ln'. dst ofdrogs 10 v.Ijdt /IIf$t fIri"i Dim IfP):
BETA-ADRENERGIC BLOCKERS
Of the subclasses of adrenergic antagonists, only the betaadrenergic blockers are considered first-line drugs for the
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01",1<,21
315
AdveIW Effects
oKrilnoioi (SffirJI)
~alolO( (KrrIonr)
biIoproIoI(abm)
oadolol (CDI'}Ird)
piIdoIoI(Virun)
Drug
BETA-ADRENERGIC ANTAGONISTS
ALPHA,-ADRENERGtC ANTAGONISTS
Ii.
Q rIoxal!Jlin (Cilldura)
teruolin (llytrin)
M or
Firg-9ose Dhroomenort@drKiJrdia,!IystioN
donidor (Uiaprl'sJ
m~h)'klopa
(AIdorntI:)
(jIanulomoprnia
(COII'g)
(tIormodynt, Trandat~)
HtfldodIt,dnlWlirltlJ,Dt/y,dfprruioo,kf""gy,
impoltOO!
Bm!Ymdia may WOlin! hNn faHu~ jJ)d mall!;
I)IlW!pIDI of hypoglyumy
ADRENERGIC NEURON BLOCKERS (PERIPHERALLY ACTING)
~ne{Sr~~n
ALPHA,-ADRENERGIC BLOCKERS
The alpha,-adrenergic antagonists lower blood pressure directly by blocking sympathetic receptors in arterioles, causing the vessels to dilate. The alpha blockers are not first-line
drugs for HTN because long-ttrm clinical trials have shown
them to be less effective at reducing the incidence of serious
cardiovascular tvtnts than diurtties. \'/hen used to treat
HTN, the alpha blockers are usually used concurrently with
other classes of antihypertensives, such as the diuretics.
Doxazosin (Cardura) is a prototype antihypertensive included in this chapter. Other prototypes for alpha blockers
in this textbook include prawsin (Minipress) in chapter
lJOlO , and tamsulosin (RontaX) in 'hapter 4600.
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ALPHAl-ADRENERGIC AGONISTS
The aJph<ll-adrenergic agonisf5 de<:rtase the outflow of
sympathetic nerve impulses from the CNS to the heart
and arttrioles. In effe<:t, this produces the same responses
as inhibition of the alpha, receptor: slowing of the heart
ratt and conduction wlocity, and dilation of the arterioles. The alpha, agonists cause sedation, dizziness, and
other CNS effects. Abnormalities in sexual function may
316
I DoxazOSIn (Cardura)
ADVERSE EFFECTS
On staning douzosin therapy.some I"titnts tlprrierKe It"fious orthostatic hypotension, .khough tolerancr often deeIops to this side rffert after a trw
dom. Dizzinrss and hradachr are also rommon adl'!'lW rfi"Kt5,although they
.re rarl'~ stYere enoogh to (,Ju~ disrontinuation of thmpy.
Contraindications: Douzosin is conmindicated in I"tients with prior h)optr=sitivity to alpha bIoc:keB.
INTERACTIONS
J)ug- J)ug: WIIPn givfn COll(Ull!llily, othfr .nlil)"pfnfnlim M<f adJitiH rtffCtS
with doxarosil on blood JII'SIUrI'. Oral ciMliIint m.ly GlUIoI' mild mIN51' (lO'l6j in
tht half-life ofdoxazolil.
Lab Tests: lklkoown
IlerbaVFood: lklknown
Treatment of OverdOSf: Thr most likt/v sign of 0I'!'rd0sagr ~ h)opotrnsion,
which is treated with 01 v.soprl'swr andfor IV infusion offluid~
Rtftr 111 MyMnmgn ~ a MnInIJ /'reII fooIl sp1/t 1II1M <trJg
Prf9nancycategory 8
PHARMACOKINETICS
ll1.... t Jh
Pf,ak:l~h
Half~ifto: 9-llh
Duration:14 h
Assessment
Bastlin e ISHss ment prior to administ ration:
Undmtand thereolson the drug has bren Prl'!cribed in ordtr to as~ for
therapeutic rifrcb.
Obt.in a (ompletr heakh history ineluding cardmalCular (including MI, hun
failufl'j,musruloskeletal (pre-rmting ronditions that might r6Uk in f.tigU!',
Wl'iknffi, IlI/ICI!- or jointl"inj,and the ponibilil)' of pregn.ncy.Obtain 01 drug
histor, ineiudinj .lIelllies,cufTl'm pR'I(ription.nd OTC drugs,herb.J1
pR'pir~tioM, ard akohol UII'.8t oIlrn to pcmiblr drug imrractions.
E"liluatr appropriate laboritory findings, electrolytt-!, ~ioIll)' potmilm 1M,
gUcosr,hrl"tic and It'IIiII function lIudie, .nd lipid profile.
Obtiin ba~linewrigh~ vitll signs (eprcioll~ BP and pukel, brllllh sound!,and
<llIlil< monitOling (. g. [CG,<lIrdil<outputj ij IPPropriat. ,..",.. for the
location and chuac\l1f{.moum of edemol, if prmnt
Assessment th Rl ugh out administrat ion:
As\o!"l5 for desirrd therapeutic effrclS (e.g., Iowrred blood prrS~fI' within
~stiblished limts).
CominU!' frr~m and <afl'ful monitoring ofvital signl,liaily wrighl,.nd urinary
and cardiolc output .1 appropnatr, eJlf<ioIll)' if IV admin~tration is used.
CominU!' prriocfKmonitoring of electro/ytt-!,tlJIf<ioIll)' potassium.
As\o!"l5 for and promptl)' repon adl'!'M rffrcts:bradjUrdiol, hypotension,
dysrhythmioll, rtflu tachycardia, dizzinrss, hudac:he, or drcfl'.sed uriniry
output. Sr'/ffI' hypotension, ~izurrs. dysrhythm ioI s1l"lpitationl may indicate
drug IOJKity oIn:1should be imflll'diatr~ rr poned.
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0I ..1I0I2l
ON9,/orliype"en,1on
3 17
Hift thr pat~m weicjh ~ cbily, idtal~ at thr >IIIII' tillll' ofday, i nd
1I'(0rd Wl'ight along with blood pressurr and pullf mNSUlI'lIII'nts.
Hift thr pat~m II'port a w~ht giin or Ion of moll' than 1kg in a 24hour period.
Give thr first dose oftill' drug at bedtimE'. Obserie for excffiive drowsiness.(A
fir;t-doll' II'sponSf IIIiI)' rf"IUk in ~ greater initial drop in BP than subsequent
dosts. Some adrenf rgic: blor:ken may (lust lignifiunt drowsilll'Ss and are ulf<i
uutiously in the eldfl'~, who arr at risk furfalls.)
InslnKt the patil>nt to take the fir;t dose of medic:ation at bedtime ~nd
ContinUl' to monitor blood g1ucOlf and approprine lab 'Mlrl (AdR'nI'''l ic:blocking drugs may intfriere with sOlllr 0IiI1 dgbftK drugs or{harqe thr way iI
h)'p09l){tmic: lI'oKtion is peltfiYfd)
Assess thr patient's mfOtal SUM ind mood. (Adll'lll'lllic: blocker; m.ly UUII'
~ionordysphori . )
(Conr/ooefi)
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31 8
Provide IoH'yl'{omiort wch on an adequat~ righted room.(AdrentI1jKblocking drugs yn (,JUS!' mm~ and dilfKull)' Iffing in low light 1t-i~1s.)
Th~
Evaluate thl- fff~1H'1I ofdrug thl-rap)' by {onfirming that patient goals.nd ~~d OIJ\(OIll!"l ha~ ~n m~t (Iff "Planning; .
Sn T!It 116mdtr'Blf~Baklrr"f()f~ Ii5lddrII!P /IIwNchrhN rrIIIinglion!~.
"t
minoxidi ( Lon~m)
nitroprussidr (Nitropresj
IY;OJ-{I.S m(glkglmin
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Adverst' Effects
Orllm!~rk hypoleruion, nlJid fIIlmlion, htododIf, polp!~~rka;
IUDII" "
If1joo !jMJ9!azilrJ
dYsrhythmia~Wod
IfWl' bypotrolj:m MI
~1tf21
Prototype Drug
319
I Hydralazme (Apreso/me)
.
.
DN!lSfOf liyplftenslon
ADMINISTRATION ALfRTS
Abfupt withelfjWill of the dfU9 may ~e rebound hypenrnlion .nd
mil'\)'.
Pm}n.nryut~(
ADVERSE EFFECTS
reIitlt.a.yardia, palpiutiont, IkIshing, MUlti and di.Jnhu Ire
common, bIIt IM1 reo!VtilWripy progresse. Pjti~1Il5 taking bydrlLiZiM of
1m rectiw a bftHdreMfgic bI<Ki:ef to (ountmct reflex ,acbrwdia. Rile!);
thr drug may procb:r lup.lllike syncIllllf'If mil IM1 ptMt for 6 mood!! 01'
Ionge-. SodiJm .mel i\Jid retmtic.n is. polftlti.lliy smous.~ rfrKtBf,UIM of thtse ad_ tffKlS, the 1M of tr,dr1lizint is limited fl'lMtty to p,itients whose 11TH unnot ~(ont,oItd with othtr,wftr mtcI'KaOons.
Contraindimions: ~ of ilS tffts 011 tilt heart, hyd,aliziM is COI"IIIaindicutd in p,itifnuwih iIlgiJ'll,rhtumltic llt.n<b~Ml,ofTj(h)Qrdi
Patiel1u with lupus shoukillOl meiYf hydraluine, is the elrug rail \\'\lOtfI
symptOll\'l.
~ht,
INTERACTIONS
Oruc.t-DfllJ:AdrriMllmg b~1II' MtlllIItw an~m.irall\f
_
PHARMACOKINETICS
Onstt:20-30 min PO; 10-30 min IM;S-20 min IV
Ptak:Unknown
Halflife:3-7h
lMation: 2'" h
Direl;t vasodilators produce nfla ta(.J(lIii, a w m pensatory response to the sudden decrease in blood pressure ca used
by thl- drug. Reflex tachyc:ard.ia forces the heart to work
harder, and blood pressure increases, counteracting the effect
of the antihyperttnsive drug. Patients with coronary artery
disease could experience an acute angina attack.. Fortuna lely.
refle.'\" l:lch)Ordia can bf prevented by the concurrent administration of a beta-adrenergic bJocker,wch as propranolol.
A semnd potentially serious side efft"(t of direct vasodilator therapy is sodium and water retention. As blood pressure
drops, blood flow to the kidneys decreases and renin is released as the body activates the RAAS mechanism. Dueto the
vasodi lation caused by the drug therapy, the angiotensin released does not cause-vasoconstriction. but doesst imulate the
release of aldosterone, causing the kidneys to reabsorb
sodium and thus water. As the kidney retains more sodium
and water, blood volwne increases, thus raising blood pressure and canceling the antihypertensive action of the vasodilator. A diuretic may be administered wncurrentl y with a
direct vasodilator to prevent fluid rett'ntion bu t warrants ex-
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HerbaVFoM: Unblown
320
UnII4
lheC~,dklYascu~,
Aue ument
Bileli.e 1_ll lIIe ~t prior toitdmin btr. ion:
Undersund "" rrl50n "" drug III! IieeIpreaibed in otdtr to ilstSllor
""'~pNtic tfmts.
""'nl
Risk b kIjwJ (of91n sysums;rdaltd 10 adftnttlltsol' dIug
1ht.-~fIY)
""'nl
Drficimt~(dniqthmpy)
"lhelYlinltd
Exptlitnu thmpevtit rffts drptndel"lt on the _
tIIedlug is IttWlg cjtnJ (r..g.. dtml1td blood plftllft).
kfHtfro!n.Off~min_MIotswrffrcts.
~iII ~~901thedN9IU1t,~rffKts,.ndltCpJirtd~ltJIiofts.
tltmonllT.1e proptr stIf-.dmil isll.tion 01' tilt mtdiQtion (e.g. dolt, tini1g, whm to natly ptOI'idrf).
Impltmentilltion
Inttl'"ventio nl a nd (Ratio nales)
IRllring thffilpeutit elfetl l:
u.minue IrrlJlent l:ilnsnltml.s.bow lor thmparlk rifutl..lV infusion 01
IIodi~lm may be litrlled Ir!qutntly to i(hit'l!! desirtd dlfm.Vitillsiglll,
(.!!Iii( ilnd urinaryoutput,.nd daily wtights should ~in within limits Itt ""
mr ht.kh cilrr providtr.!Pulsr, blood prtSSUrt,ind rt1pif~ tOf)' fatf lhould be
within nonnil ilimitsorwithin ampublt paramettrs.An i/ICrt.~ in wtight o~r
1kg {approllimitely lib) per day may indiotf ectSsWe Huid ipin ilnd m.y
rrquirt judkious diJrtlic ttrfflPY.)
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CIIopttr ll Drug./ortfypMen.1on
]2 1
Whtn on col thtrlpy ill homr, teach IIIe patien~ famitr,or caregiwr
10 immediattly ~pon (MIIgH in mmul mUll orletlof
cor&iGusnesl" palpitations, dizzintll" dyspnu, inmuinq prodllCtift
couqh (ejIiaIly if frothJ'pulum iI p~nt).
Wtiqh tlrr jIoIDrIll daily and It'pOrt a weigh! gain or Iosl of 1 kq or more in 24hour ptriod or signific.lnt ~helill tdrm.l.(D~ily wright: iI an i(ur;ne mtalU~
of fluid !taM,nd likes into oKCOUnt inlilkt, OUIpU!"nd inlenliblt 1osst1.)
f1H oral drug mrlilpy,gM tht finl doseof IIIe drug at bedt.inIr. (A Iint-4ose
rtIpOlIIf IIIiIJ JtIIIIt in i glUl~ initial drop in BP tllin Usequent rIo!e..)
T9Ch dlt patient not 10 st.. mediutioa abruptt, iIld toa.1I tilt
hta~h cart p!OYider if patiffit iI ulliblr to like mediQtioft for ~
than 1 day Ib to iUne...
:c-:-'---:----::-
me
---:-::---c:-:-:--
iii"
Tilt patimt should be.bIe ID lIall' IIIe reilson for IIIe drug;
.ppropria~dosr and IdmLling;what ~r rflKts to oo.rMJot.nd when torepart;.nd thr .micipalrd lenqth 01mediution thmpy.
{COOIJncJed}
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322
UMl4
"m.
Evalu at ion o f Ou tcome Cri te ri a
Ev.JIuolll' \he, rffKtiftllffi of drug tlitral'1 b,<onfinninq thilt paoot goal!.Jnd I'JpKtedouko~ hift ~n !lid (~"l.Joning1.
,pp/ttnifIII_.
23l
23.'
D.3
Cakium channel blockers block calcium Ions from entering cells and cause smooth muscle in arterioles to re_
lax, thus reducing blood presure. CCSs have emerged as
major drugs in the treatment of hypertension.
23.9
23A
Blocking the renin--.angiOiensin system prt'VenlS the intense vasoconstriction caused by angiotensin II. These
drugs also decrea.sl' blood \"Olume. whidr. enhances their
antihypertensive effect.
DS
D.6
Be\:ause ant ihypertensive medications may have uncom fortable side effect"" lifestyle changes such as propt'l" diet
and exercise should be implemented prior to and during
pharmacotherapy to allow lower drug doses.
Pharmawtherapy of HTN often begins with low doses
of a single m edication. If this medication proves ineffec-
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~ttrl)
OrugtfOfHypertemlon
123
NCLEX-RNOREVIEW QUESTIONS
drug Ihenpy!
1. Ab<;enceof edema in kMerextremities
2. Wdghlloss of 61b
}. Blood pressure Jog notes blood pressure 120!70mmHg
10 134/88 mmHgslnc:edJscharge
sium lab result Is 2.5 mEq. The nurse's besI action Is to:
1. hold the medication and notify the health care provider.
rompllance.
}. !here is less daily medication dosing.
4. rombirution thenpywU! treat the patient's other
medical oonditions.
The dass of antihypertensives that Increases urine production by affecting the renin-angiotensin- aldosterone
pathway Is the:
I. calcium channel blockers.
2. adrenergic blockers.
3. ACE inlubitors.
4. dIrect-acting vasodllators.
The nurse is preparing [0 administer the first dose of
ena laprll (Vasotec). Identify the potential adverse effects
of this medication: (Select all that apply. )
l . Reflex hypertension
2. Hyperkalemia
3. Ptrsistent ooug.h
4. Angioedema
5. Hypotension
A patient with Significant hypertension unresponsive to
other medicatIons Is given a prescription for hydralazIne
(Apresoline). An additional prescription of propranolol
(lnderal) Is also gi\'en to the patient. The patient inquires
why [wo drugs are needed. The nurse's best response
would be:
I. giving the !ml drugs together will lower the blood
pressure even more than jusf one alone.
2. the hydralazine may cause !achycardia and the
propranolol will help keep the !lean ra!ewithin normal
limits.
3. the propranolol isto pmoentlupuserytbemat06US from
developing.
4. direct-acting vasodiwtors such as hydralazine ca\.lSlli' fluid
retention and the propranolol wiD prevent excessive
fluid buildup.
r::::=:-i~-'---,
EXPLORE ~
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m!ler\a15 alld
n!\'I!W
at
DRUGS AT A GLANCE
LEARNING OUTCOMES
~J}6
Q "Jlnopr1l (PrtnlVlI,Zestlil)
DIURETICS
PJilI 119
pilrJtJ19
CARDIAC GlYCOSIDES
{II19tJJO
roqt1Jl
""m
VASODILATORS {II19tJJf
PHOSPHODIESTERASlINHIBnORS
ANDMISCElLANEOUSAGENlS ,..315
Q
mltfnone (PrtMrot)
pot}t JJ6
KEY TERMS
dtfrload pr19tJlS
(imliac output (!JfJt Jl5
tardi ~modf~ng po!Jt j}6
contradility fXl9t J2S
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inotrolliuffffi
~ l15
ptriphtraltdtma fJlJ9fJ}6
pholphoditlttrast r;II9tJJ$
Jnloid {IIl9tJ15
to increase as the population ages. Despite the dramatic decline in mortality for most cardiovascula r disease (CVD) that
325
has occurred over the past two decades, the death rate for
heart failure has onl) recently begun to decrease. Although
improved treatment of myocardial infarction (Mljand hyper-
however,because not all Incidences of this disease are associated with congestion, the more appropriate name is heart
failure.
MI
Chronic HTN
Diabetes mellitus
Because there is no cure for heart failure, the treatment
goals are to prevent, treat, or remove the underlying causes
when possible. For example, controlling lipid levels and
keeping blood pressure within normal limits reduces the incidences of CAD and MI. Maintaining blood glucose within
normal values reduces the cardiovascular consequences of
uncontrolled diabete>. Thus, for many patients, HF is a prev~ntabl~ condition; controlling a .... ociated di.ca.c. will
PHARMFACTS
Heart Failure
Heart fJiufl' (Hf) ilKfI'j~ with age. k affect!:
1% of those 40 to SO)'!'.<lB old.
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326
I
D"",,,,,,,,,d blood pre5l!Ure
I
Pulmoollry edema
11'~! ~-;
.....,
peripheral
Edema oIlimbol
Increm!Mld
,~"""'"
moo
water
Increased
,,,sistanca
blood volume
Incre ...... d
altarloed
myccardiat
""'"~,
~
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ACE inhibitors were approved for the treatment of hypertension in the 1980s. Since then, research studies have
Reoin-angioteosin
system activatad
Sodium
I
ADH
CNp1tI24
Drug. /0,
Hf'artF~lluf"
327
PHARMACOTHERAPY ILLUSTRATED
24.1 Mechanisms of Action of Drugs Used for Hea rt Failure
= Sti....lalion
= Inhibition
Adrenergic; block...
o..c......... cortliac
neurons
pmIoad (Elo.ample:
;.o1Kl/bide dirilrale)
Pho.phodie. l . .....
inhibitor.
<a~!~tInc ........
cardiac
~
by
r.creasing
theoutput
f"",. of
myocardial oonlraction
(Example: milri""",,)
AC E inhibit or.
Inore&H cardiac
output by Iaft'ering
blood preo.s<n and
dec..,BIIing ftuid
"~
(Ellample: lieinopti)
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show equivalent efficacy to the ACE inhibitors. Valsartan (Diovan) and candesartan (Atacand) were approved
to treat H F in 2005. Because research has not yet
demonstrated a dear advantage of ARBs over other
medications, their use in the treatment of H F is usually
reserved for patients unable to tolerate the side effects of
ACE inhibitors.
Please refer to Nursing Process Focus: Patients Receiving ACEI (Angiotensin-Covering Enzyme Inhibitor) and
ARB (Angiotensin Receptor Blocker) Therapy, page 312 in
chapter 2300, for additional information.
Adverse Effects
gploprIl~~)
Iftdht.~oltholtllfk /IfportmM.COIJ9/l
"'""
ACE INHIBITORS
Sm!~m:I!!l!t!l1!!!! If.s::!lmDl\( "OI'M!Q(II'll!!!2~
aoo ipcslrm.
ProtoCJpe ~ boxCIO)
fosilopril (Monopri)
PO;HOmt/clI, (nlu:40"9'doy)
o IiIilopriIIPrillMI,Ustril)
lPlliipril (AcCl","O
r.mlprl (,IJta(t)
blood d!ry"w,
"fOIISlio (liIwan)
DIURETICS
IMIntlillido! (BuIael)
l.oop,ndtlllizi~
fIro5oM'lklt (Lm)
lontmide (1)eN6ex)
(max: 600m~1
Y.
PO:lS-ZOO mg In i
dow or !Ilrff
1'I:iI:111i\Jn.,pui"ll:
PassIum-Spdting (AIdosI!tOUAllfagoolliJti
tpltrfllOllt(lO\ID)
"""""
'' ' '
o
mttoprolol91.et*d rtlw~{1opro1-XI.}
iltSllllllht
1Ndyc,.
aJllMion
~
dnIor5intU.~r orllcltitSldibldrl,.
Ag@nu!ocytosij.Wyrm!lW"Sfmm- )obrnr.rt
i!!!!i!!m iI!!ilR!!!!i!irif!!! ~r!o!il il i!!!1!1b: 'll'il!Wwn
ptlpit.nioM, ttixI!!Id hmffi!l!iDll W~ thl9ltr1ioo
rtryhytbmjA, or mrordal jyhrmia iN. OI'QII
OIRECTVASOOILATOR
~ (N.no=r)
Hftldhf,/lII/IqIl'IICt,.mw'rk~
PO;O.llHSmg/daJ
DnrhythmLu
CARDIAC GLYCOSIDE
PHOSPHODIESTERASE INHIBITORS
iwmrinont (1_)
o rriIrI"Ior1e (PTirrvtor)
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HmdIIt,ftJP:lF1'fIIion
Dnrtrythmwi
CNplfl 24
Drugs /0,
1-1<>"" F~IIu,,,
329
ADVERSE EFFECTS
lis inojlil is toleraled well by most patirnt~ Th~ most rommon adv~W' ~m
aft' coLgh, headac:he, dillinl'll,orthostatic: hypotenlion, and rash. HypMcal~mi.J
may ocrur during theC"apy; Ihus, Mc:trolytt Itftls art usually monitored pm
iea lIy. Dlher ~ffec" indudt taste dil1urbi IKn,{hfit pain, nau IN, VOID itirg. and
diarma .Though rare, oI ngioedmloi is 01 W'rious adW"II' dl.
Contraind icationl: lisinopril is (ontraindical~d in j)iltienll with ~yper
kalemi! and in thos~ who have prn iously 9per~IKed angiOl'dtma "used
by A(Einhibilor therapy.1t should not br used during pft'Cjnancy brUlU it is
a calt<;0ry 0 drug during the s~ond and third trimfltm .
ADMINISTRATION ALERTS
PHARMACOKINETICS
Onsd: I h
INTERAalONS
DrurOrug: InOOrnfthidn III 0!IlfI HSAIl); may i lleoo with wnoprit ( AIIilj
~anlihypHltnSiwani";Iy. SKaustoftMaMtivfh)"poltnSiwanion d
Iisinopc1 and diantia, combiIfd tMrapy with ~ or 0!IlfI anlih)1Jfrlfnsft d"ugs
shcUd W~ monitorfd. WIIfn isiIopri is taken COIKII"rl'flily with potiS.WI)
sparilg dilROO, r,pHbIMU may Mi.lisinopril may ooa", lithilln ImIs !lid
IaUII' illium IOIicil~
l.i b Testl: May {jIM positiw MA titH and MNs.! vakJrs of thco folowing: 8U H.
IfnIIl tiintlin,lfnIIl albinf phoIp/Iatast,.l.SL and N..1
~k :6-8h
Halflife:12h
Duration: 24 h
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di uretics are also able to function in patients with renal impairment, a n advantage for many patients with decompensated HE Another major advantage in acute HF is that loop
di urttics act quickly, especially IV formulations, which work
within minutes.
Thiazide diuretics are also used in the pharmacotherupy of
HE Because therare less effective than the loop diuretics, thiazides are generally reserved for patients with mild to moderate HE They are sometimes combined with loop diuretics
to achieve a more effective diuresis in patients with acme HE
Potassium-sparing diuretics have limited roles in the
treatment of HF because of their low efficacy. Spironolactone. however, is an exception. In addition to being a
potaosium-sparing diuretic, spironolactone is classified as
an aldosterone ,rntagonist. Clinical research has demonstrated that spironolactone blocks the deleterious effects
of aldosterone on the heart. Spironolactone ha$ been
shown to decrease mortality due to sudden death, as well
as slow the progression to advanced HE
Please refer to Nursing Process Focus: Patients Re.:eiving
Diuretic Therapy, page 305 in ch~pter 23010 , for additional
information.
]]0
UnII4
I Furosemide (LaslX)
PharmcologicClass: Diuretic(looptype)
ADVERSE EFFECTS
~1Il' efIeo:u of furoStillidl', lie thole of mon diuretic:s, iOYOl~ potential
t leurolytt imbalan(fS, tht !IIOII imporum of which is hypokalemia. BeuIM
fur=mide is 10 t fftoctiYe, Hu id 1015 mu51 bI> carefully monitOfl'd to pft'\'ent possible dehyd'<ltion ~ nd hypott nsion. HypoYOlemi.J may call1l' orthostatic: hypotension.nd synropt.
Contraind ica\ions: Contr~indicatioos indude hyper lI'ositil'ity to furostmide or
sulfon 1m idI'~ .nurY, hep.atic (oma, . nd 1I'"lelt' Huid or tleurolyte depletion.
INTERACTIONS
1Wg- 1Wg: BKIUII' ~pokaIeaja may<aU\f d)'ilh)l/lm~ il pati@nts!DIg
GlI1bc: o#osidM, (ombination thenpy w;m dgoIin mll5l ~ <afefUly mcmor~
{oo(Wfl'nt Ull'with rortkostflOid!,~lfriti1 B,orodlfl po~~u~ng
Lab Tests: futI\.Iom_ milY ilIrtR Mil@! foI the foIoMog: blood ghKOIf, BUN,
\8"l1li aIII)'liIt, (hoIfsnorol, trigIywidn.
m_
fIfctroI)1H.
IlerbaVFoo:l: I..IrUown
PHARMACOKINETICS
il1l1't 30-6) min I'O;S min IV
~.k: 60- 70 min 1'0;20-60 min
IV
Half~ifto:
3D-60min
Dur. tion: 6-8 h PO; 2 h IV
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feets may result from lUlfllonitored t reatment. Digitalization refers to a procedure in which the dose of digoxin is
gradually increased until tissues become saturated with
the drug, and the symptoms of HF diminish. If the patient
is critically ill, digitalization can be accomplished rapidly
with IV doses in a controlled clinical environment and in
which potential adverse effeets are carefully monitored.
Patients who begin treatment outside the hospital may experience digitalization with digoxin over a period of 7
days, using or~1 dosing. In either cas.. , the go~J is to deter_
mine the proper dost' of drug that may be administered
without undue adverse effects. Frequent serum digoxin
levels should be obtained during therapy, and the dosage
adjusted based on the laboratory results and the patient's
clinical response.
(Antagonists)
Cardiac glycosides and other drugs that produce a positive
inotropic effect increase the strength of myocardial contraction and are often used to reverse symptoms of HE It may
seem surprising, then, to fmd beta-adrenergic blockers-drugs that exhibit a rregaril"e inotropic effect- prescribed
for this disease. Although this class of drugs does indeed
PHARMACOKINETICS
Onset: 111-90 min PO;S- lO min IV
Peak:~ hPO;1.S
33 1
h PI
Halllife:1--4 days
~n: 6-8da~
have the potential to wo rsen HF, they have become standard therapy for many patients with this chronic disorder. Only two bela blockers are approved for the
treatment of H F-.....Q.rvedilol (Coreg) and metoprolol extended release (Toprol-XL). The doses of these agents are
listed in Table 24.1.
Patients with HF have excessive activation of the sympathetic nen'ous system, which damages the heart and leads to
progression of the di<ease. Beta-adrenergic antagonists block
the cardiac actions oi the sympathetic nen'ous system, thus
slowing the heart rate and reducing blood pressure. Workload
on the heart is decrfased; after several months of therapy,
heart size, shape, and function return to normal in some patients. Extensive clinical research has demonstrated that the
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ADVERSE EFFECTS
The most daogtfOUS adYme tffra of digoxin is its abilil)' 10 (lNte dysrhythmi is, pmirularfy in patirnts who hal'!' h)'pokairmia 0' impaired I'I'ni IfUKtion.
Beow diurtliu can caUIl' h)1Kbirmia nd ,,~ often UII'd 10 Il'I'al HF, (Gocur
I'I'm Iv. oldigoxin . nd diull'tiu must beca,tfully mooitOll'dOther ad!'J1I' rfncts 01 digoxin thrr.Jpy ind~ naUSN, vomiting,latigut, . norexia, ,nd mual
disturlBntfS suc:h is ming halos" ~Iow-gll'en linge, or burring. I'triodic
serum drug lewis should be obtainrd 10 drtrnninr whether the digoxil (on(entration is within the theraptUtil: range.
Contraindi (ations: PaUton with AV block or !'Iltrirular d~rhythmiu unrelated to HF !hoold nOI re<tiYe digoxin bK.JUIl' Ihe drug II\a)' WOBrn theW' (onditions. Digoxin YIouId be administered with caution 10 oldtr adults btcausr
thell' patients aptrience a higher ilKidenc:e of adYl'llt tffrcts. Patients "l'iith renal impainntm should re<ffle mr doll'! 01 digoxin, beuull' the dllJ!j is a(1'I'1rd ly this route. The drug should be UII'd with caution in patirnts wth MI,
(or pulllOnale,or hypothyroidism.
INTERACTIONS
DrurOrug: Oigolillilmm wilh many trugs. Concwrenl UII' of digolill wim
diu rHiG can IlIUII' hypotakomia and irKri.R the rilIr of ~)"!hmial.lJ\.! wim ill
mllilcn,spiOlloiaClOfll',OI potmium \~HllPntlcan INd 10 ~ and
reduce .... the!apMiI: iOion of digoxin. AOOIililtr. tion o f .il with other
poW"/I! iIouopic agenlS yn aulo! ol6di~ effioaI on hoo <llIlIiKlility. Cooo.wIHIt
!lie wi~ beta bIockHI may ,t\Ifi il addiIi~ brody<;lldia. Antacids DI dIoIfIIeriIowfrill OOM)I can dKrNIe the absorption of !igoIin.1fuki:.m ~ olOOiiniliered IV
~with digollin,it un ilafilo! therilkol ~)thmiA ()inidiM, vmponi,
am iod.Joof. and a~ will demu the diltribulion and exuetion of digolin.
thu! inaNsing the rill; of digcl:il tollidty.
La bTl5IS: Unknown
Herbi Hood: GiRSfng may ilafilo! the riIk 01 digollin 10D:it~ ilia huang .and
ephfcIr; may ilriKt d)Yh)11v1iu.
Treat ment of Overdos!: Digoxin CIVffiIoII' un be fatal. Sptc:ific therapy illwlm IVinfusion 01 digoxin immulII' lab (Digibind), which contains <IntiJodiH
specific for digoxin.
IIrftr III M)NUIlIIJqm Alr Q Mmlnlj Pnxrll fIlM Jp1k III/lis drug.
pro per use of beta blockers can dramatically reduce the nwnber of HF-associated hospitalizations and deaths.
To benefit patients with HF, however, beta blockers
must be administered in a very specific manner. Initial
dose, must be 1/10 to 1/20 of the target dose. DOles are
doubled el'ery 2 weeks until the optimum dose is nached.
If therapy is begWl with \00 high a dose, or the dose is increa.\ed too rapidly, beta blockers can worsen HF. Beta
bloders are rarely used as monotherapy for this disease,
bu t instead are usually combined with other agents, especially ACE inhibitors.
The hasic pharmacology of the beta blockers is p r~sented
in chapter 1300. Other uses of the beta-adrenergic blockers are discussed elsewhere in this text: for hypertemion in
"
ll2
Assessment
I".,."'r.II,.;,.""o ,."......o..,,,,
TeiICh The patien~ family,or ull'9~r how to mooilOl' pullt and blood
pttllUrt. Enill,e tilt proper \/If and fUnctioning of any hoJlll'
equipJlll'm obtaintd.
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IlIopltrU
Drug<forH,,;mF~llure
]3]
Weigh tMp.atRmdailyand ~rtaweighigainOilossofl kg OItIIOIII:in .24hour ptriod. (~ily weight is .ft acrur.1t measure of IUd SUM .nd ukts into
I(OUnl int'R,output,and M~bIt Io!m. 'Neght gain 01 edtmil Ny signal
imptnding hra" f.ilurt with ffIIucfd organ ptrMion,mmuiating ltIIin
!tItale.)
Monitorforsigns of woneing hNrt faiIIR (t.g., inCINSing dyspnu 01 poItur.J1
ftotturnal ct,spnu, ralft OI "aad\ts" in kirI9I> frothy pri.lin~ lfIUIum) .nd
reporl immt<imly. (If signs iIId symplOfM worsen,otlle trtalmtnt options may
neoedtoMmmideredJ
kJluatt thr ~I of drug therapy bJmnfinning that patient goals otrId txpttd OI/I(ome h.'/! bffil rntt (_"PLinning1.
Sfr WIlt l4.11111l1ff"rardiK ~f(lf_ittrnMionoborKlf9IDr.
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ll 4
ADVERSE EFFECTS
Metoprolol is stlKti~ beta ,-,drfll~lIJic bIoc:krr , '/<Iilllble in t.bltt, sus"inedreIt.se table~.nd IV fonns.At high~rdos6, it m.~ .Iso.~d bm,l"f(tptors in
brondlial smooth IllU\(te. The drug ..cIS b~ rroucing sympnhetK Slimul ilion of
tilt lItart, thus de<~'lIiog cardiac workload Metoprolol h~ ~n found to slow
the pI"Ogl!1sion of HF and to sign ifiuntly rmt tht Iong-tt nn oonsequtnm of
tht di stali'. k is usu.11y combined with other HF drugs IUCh <II ACE inhibitor!.
Metoprolol isako .~ for angina,HTN,and for rro!Kiog urdia[ rompiiutions following an MI.
BaIM it is selectMo for blocking 11m, rKtploo in the he,,!, IIII'toproiol has
flow adverst e~cts on othtr autonomic targets and thus is prefer~ ~r nonselectiv~ beta bIoc:krrs suth as propraoolol for p;ltitnlS with repiratory disorders. ~rw ~ffKtl a~ genmlly minor and ~lat~ to its .utooomic .ctMty,
IUChassiowiog oftht hean rail'.nd hypotension.~us~ ofits multiple ~lIeCB
on the he,rt. patients with hean failu~ should br urefully monitorro. Dthtr
frr~m adYerll'effrcn inckidt abnormal sexual function,drowsi~~ fuigue,
<l ndifllOll1nia.
Contraind ications:This drug is contrai ndicufd in patients with <ll1hma, cardiogrnic shock, ~nus brad)'Cirdiol, ht<ln bIoc:k 9~ut r than first deg~t, and ~I
u rdiac failu~.
ADMINISTRATION ALERTS
P~nanq category C
PHARMACOKINETICS
with Vasodilators
The two prima ry drugs in this class, hydralazine (Apresoline) and isosor bide dinitrate (lsordil ), act directly to relax
blood vessels and lower blood pressure. Hydralazine acts on
arterioles. It is an effective antihypertensive drug, al though
it is not a drug of first choice for this indication. lsosorbide
dinitrate (lsordil) is an organic nitrate that acts on wins.
The drug is not very effective as monolherapy,and tolerance
develops to its actions with continued use.
Because the two drugs act synergistically, isosorbide dinitrate is combined with hydralazine in the treatment of HE
BiDii is a fixed dose combination of 20 mg of isosorbide
dinitrate with 37.5 mg of hydralazine. The high incidence of
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INTERACTIONS
I)ug-l)ug: ~t US!' willi dMpDr may rM! il bradyan!ia.lhl
IIlriKfjIIi"115 may CilMincrmed mM~ etft<ts.lMwithakOOolor
Lab Tl5Is: M!loproloi may incrNlf ~ for the IoIowiog:uric add, ~pidI,
pot.&ium, bi~rUJil, alllillint ~UII',(J&1Iinilll',and antiu:lHr antJ:oocly.
III'rbaVFoo:t: I..InI;nown
Treatment of Overdose: Atropint or isoprot~rrnol can be us~d to ~
br.ulycaroia calISI'd by """,,oprolol OYerdoIl'.Hypotfllsion may be ~r>ed by <I
nsopresor sum as p.~nteral dopamin~ or dobu"mine.
(lgp", l>I
H OME
-
&
C OMMUNITY C ONSIDERATIONS
----
-----
ns
,n-
~IIJ"fJtluntr"lOr~l~
01 'Mig1"l1M\.
.I
--":Ih tho btMin.~ pltifnb CiA l1li10"9"" ~.. whot they (1)11-
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~nOOon","'cI,ignifiu"'bentfitintfltwro:ino!pOl1S~
))6
1tIIIM .
I Mllf1none (Pnmacor)
PhannlCologlc Clm:
patients.
PrtgMncy utt90tY (
Phosphodi~@fase inhibitor
ADVERSE EFFECTS
~ most seriIM ~ ~1fKI of milrinortf is Y!rtOOrlar d)oI;r!Jythmil, lWiich
IIIiY O(cur ~ 1of ~ 10 patientmking tile drug. The p,atienl's ECG IIr<ruId be
monitortd mrrtinUOl6ly IiJring the inMiOl'r of tilt drug. 8Iood j:ftlMJrt is .110
conrinLlOlllIy moniIDrtd during IfIt infusion to prt'lft\t hypottmion.ltis serio
ous side tffts in<kIdt headache,n,usea, and 'oOmitillg.
Cootraindications: The only CDIItr3indiotion to mimone is prtYious hyper
-ivily to tilt drug. Milrinont should be used with uution ill patienB with
pl(ftisting d)oI;rlrythrniis.
INTERACTIONS
trug-q MiRilnt ilfr.Jl:nrilr ~r.mo..lilllillJu:ecirt hypotl'lllialL
Cntion sboItI be IIsed wilen admiMlllmj miri_"lritbligoxill. dotrdlinllrw, (If
GIller mtropitliMJl,WIO' thIoir pMi.,.. ilKKfOlic .tfem. tMlINrt ~ be
-..
PHARMACOKINETICS
DlittHOmin
PI!":IOmin
Half~ift:3-6h
Dur.Iion:Yariablt
L Tesu: lIIIbIown
IifmVFtod: LnI;_
. :i Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct sununary of the important poi nts from the corresponding numbered section
within the chapter. If any of these points Ife IIQt clear, refer to the numbered section wi th in the ch.apter for review.
24.1 Ht'art failur.. is clo!;.-Iy associated with chronk hyperten.
blood pressure, reducing peripheral edema, and increasing cardiacoutput. They are drugs of choice for the treatment of HE
load and decreasing the ca.rdiac workload. Nesi ritide (Natrecor) is a newer YlIsodiiator approved for the treatment
of acute HE
24A Diuretics relieve symptoms of HF by reducing fluid overlood and de<:reasing blood pressure.
24.5 Cardiac glycosides increase the force of myocardial contraction and were once drugs of choice for HE Because of
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NCLEX - RN ~
REVIEW QUESTIONS
Nursing inlerventioru during initial therapy with ACE inhibitors must include:
I. monitoring ECG.
2. monitoring intake and output.
l. monitoring blood pre5SUre.
4. monitoring !IefUITll~
3. 0XIg.h.
4. diuiness.
5. headache.
The teaching pbn for a patient receiving thiazide diuretIcs should Include:
1. taking the apical pulse.
2. including citrus fruits, melons-and vegetables In the
d.
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,------- ~.------,
EXPLORE ~
www.mrnuru.akll can .
Chapter 25
Drugs for Angina Pectoris
and Myocardial Infarction
DRUGS AT A GLANCE
LEARNING OUTCOMES
ORGANIC NITRATES
(ia9tJ4/
p!XJt J.j)
Q diJ/lozem (Corofzem, Clift/II IT, Dilator
)(R, TazrJo Xl; TlClza() pu;t 348
",,",
Infarction.
4 . Describe the nurse's role in the pharmacologic manage ment of patients
with angina a nd myocardial Infarction.
S . Explain mechanisms by which drugs Clln be used to decrellse cardlliC
oxygen demllnd lind relieve angina pain.
6 . Ide ntify dasses of drugs that are given to treat the symptoms and
compli cations of myocardial infarctio n.
7 . For eac h of the drug cillsses listed In Dru gs at a Glance, know
representative drug elUlmp les,and exp lain their mechanism of lIctlon,
primary actlons,and Important adverse effects.
8 . Use the nur sing process to care for patients who are rece iving drug
therapy for angina and myoca rdi al Infa rction.
KEY TERMS
anginil p~dc.'is fUjt)19
'"'''''
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plaque ~1J9
si lent anginil {XJgt 11
mblranginil pt:!~11
unltabl~ ilngina ~11
vilSospastlc(Prinzmftal's)ilnginii
~ 140
339
II
trients to support life and health. With its high metabolic requi rements,the heart in particular demands II steady source
of oxygen. Should the arterial b lood supply become com-
p romised,cardiovascula r function may become impaired, resulting in angina pectoris, myocardial infarction (MI), and
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Moderate
Th......
narrowing
of lumen
occluding I..........,
partially
,OJ
~
ANGINA PECTORIS
Angina pfttc."is is acute chest pain caused by insufficient oxygen to a portion of the myoaudium. More than 6 million
Americans have angina pectoris, with over 350,(X)() nt'W
cases occW"ring each ~ar. It is more prevalent in tltose over
55 years of age.
25.2 Pathogenesis
of Angina Pectoris
The classic presentation of angina pectoris is steady, intense
pain in the anterior chest, sometimes accompanied by a
crushing or constricting sensation. The discomfort may radiate to the left shoulder and proceed down the left arm and
it may extend posterior to the thoracic spine or move upward
to the jaw. In some patients, the pain is experienced in the
midepigastrium or abdominal area. Recent studies indic~te
that women do not always present with the classic symptoms
of angina . In women, gastric distress, nausea and vomiting,
a burning sensation in the chest or chest wall, overwhelming
fatigue, and sweating may be more common symptoms. For
most patients, the discomfort is accompanied bysevere emotional distreliS-1l feeling of panic with fear of impending
deatlt. There is usually pallor, dyspnea witlt cyanosis, diaphoresis, tachycardia, and elevated blood pressure.
Angina pain is usually precipitated by physical exertion or
emotional excitement---events associated with increased
myoCtlrdial oxygen demand. Narrowed coronary arteries
containing atherosclerotic deposits pre~nt the proper flow
of oxygen and nutrients to the stressed cardiac muscle.
140
25.3 Nonpharmacologic
Management of Angina
A combination of variables influence the development and
progression of CAD, including dietary patterns and lifestyle
choices. The nurse is instrwnental in teaching patients how
to prevent CAD as well as how to lower the rate of recur-
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PHARMFACT5
Angina Pectoris
0Yer9 million ~merKans haY!' angina pectoris; 500,000 new mes oc:rur
~.uh)'l'ar.
smoking.
Myocardial Infarction
Morethan 1.1 mirIOllAmtrKans6ptrit",~aneworrerurrt'ntMIN(h)'l'ar.
About one third of the patitnn experiMC:ing lolls will die from th~m.
About 60% of the patienu who died wddenly ofMI had no p~
symptorm of the disem.
More than 20% of men and 4O'lb of wom~n will die from MI within 1 )'I'ar
after bring diagnostd.
renee of angina episodes. Such support includes the formulation of a comprehensive plan of care that incorporates
psychosocial support and an individualized teaching plan.
The patient needs to understand the causes of angina, identify the conditions and situations tltat trigger it, and develop motivation to modify behaviors associated with the
disease .
Listing therapeutic lifestyle behaviors that modify the development and progression of cardiovascular disease (CVD)
may seem repetitious, as the student has encountered these
same factors in chapters on hypertension, hyperlipidemia,
and heart disease. H owever, the importance of prevention
and mrumgement ofCVD through nonpharmaoologic means
carmot be overemphasized. Prncticing healthy lifestyle habits
can prevent CAD in many individuals and slow the progression
of the disease in those who have plaque buildup. The following f;u;tors have been shown to reduce the incidence of CAD:
Limit alcohol consumption to small amounts.
Eliminate foods high in cholesterol or saturated fats.
Keep blood cholesterol and other lipid indicators within
the normal ranges.
Do not use tobacco.
Keep blood pressure within the normal range.
Ext-rcise regularly and maintain optimwn weight.
Keep blood glucose levels within normal range.
Limit salt (sodium) intake.
When the coronary arteries are significantly obstructed,
the two most common interventions are percutaneous transluminal (oronary angioplasty( PTCA), with stent insertion, and (oronary
mery bypass graft (CABG) surgtry. PTCA is a procedure whereby
the area of narrowing is dilated using either a balloon
catheter or a (aser. Because the artery may return to its original narrowed state after the procedure,a stent is sometimes
used in conjunction with a balloon angioplasty.Angioplasty
with stenting typically relieves 90% o f the original blockage
in the artery. The patient usually receives aspirin therapy 2
hours prior to the procedure and hep.arin for 24 hours after
',,"pltll>
HOME
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341
ORGANIC NITRATES
After their medicinal properties were discovered in 1857,
the organic nitrates became the mainstay for the treatment
of angina. Theirmechanismof action is the result of the formation of nitric acid, a potent vasodilator, in vascular
smooth muscle.
34 2
UnII4
PHARMACOTHERAPY ILLUSTRATED
25.1 Mechanisms of Action of Drugs Used to Treat Angina
Sympathetic
OOrYDUS
syslom
CDR>nII'Y art""",,
Organic nitrat".
~-----------------~
25.5 Treating Angina
with Organic Nitrates
The primary theT3peutic action of the organic nitT3tes is
their ability to relax both arterial and venous smooth muscle. Dilation ofveins reduces the amount of blood returning
to the heart (preload), so the chambers comain a smaller
volume. With less blood for the ventricles to pwnp, cardiac
output is reduced and the workload on the heart is decreased, thereby lowering myocardial oxygen demand. The
therapeutic outcome is that chest pain is alleviated and
episod... of angina become Ie fr"'luent. The organic ni_
trates are shown in Table 25.1.
Organic nitT3tes also have the ability to dilate coronary
arteries, which was once thought to be their primary
mechanism of action. It seems logical that dilating a partially occluded coronary artery would allow more oxygen
to reach the ischemic tissue. Although this effect does in deed occur, it is no longer co nsidered the primary mechanism of nitT3te action in stable angina. This action,
however, is crucial in treating vasospastic angina, in
which the chest pain is caused by coronary artery spasm.
The organic nitrates can relax these spasms, allowing
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(hopltllS
Myoc.,dl.llnbn:tion
343
Adve~e
amylnitrit~
~ diriual~ (Dilallt~,lIordiQ
Sl; I tablt! (0.1- 0.6 019) orllplay (0..- 0.8 mg}MIll-) min
(max:llR ~ dosts in 15 min)
On"
Effects
ORGANIC NITRATES
HiIfo.Bid.OIlltrs)
BETAADRENERGIC BLOCKERS
-ro/eroOCt
oKtIlnolol (Sfflrll)
o atenolol (TtIIOfIIIin)
fUdoioi (Colgan!)
AannuloCYlon Ia!yomloum,
StMm )ohmoo !yndrome"natilrlam'
771
"'"
amlodipiOl' (Noms!}
Rushed~ heodocht,dniJfs~
btpridl ('I.!sI:or)
ni(lldipiOl'((,udm~)
BETA-ADRENERGIC BLOCKERS
(ANTAGONISTS)
25.6 Treating Angina
with Beta-Adrenergic Blockers
Beta-adrenergic antagonists or blockers reduce the cardiac
workload by slowing the heart rate and reducing contractility. These drugs are as effective as the organic nitrates in decreasing the frequency and severity of angina episodes
caused by exertion. Unlike the organic nitrates, tolerance
does not develop to the antianginal effects of the beta block~fS. 11,~y ~f~ iu~,,1 fUf r~li~111s wllU hav~ Imtl, hYr<'ft~l1"iul1
arrd coronary artery disease because of their antihypertensiveaction. They are considered drugs of choice for the prophylaxis of stable angina. Beta-adrenergic antagonists are
not effective for treating vasospastic angina and may in fact
worsen this condition. The beta-blockers used for angina
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""'"
344
ADMINISTRATION ALERTS
ForiV administrillion. UII' a glass IV boule .nd spKiallV tubing, beuus~
pianK .b!ort.. niuno ignifiantly, thus II'dKing the pat;"'t dose.
Clrm-the IV bottle 10 ifdKt the degladation of nitr.tes<k.ot to light fXPO\UlI'.
lJ>t glom whtn applying nitrogl)'lerin p.st~ or ointment to pr~tnt
s~lf-adm in istration.
Plfgnancy rnegollY (
INTERACTIONS
i)ug-i)ug:Cooai"II'Il U\f with ~iIII'-S inhibitoo lsiIdfnafil {V~L
YiI~ [Ltvitla],or tad.!lali IGaI~1J rna, cause IfHlni!ening ir!poten'iion.1Id
GlIliovillClllar coIiplof.!Ist with <l1coIU ...r anlil)"pHlensi'll' drugs may (;llI1f
adcitivehypotl'lllioo.
lab Tl5ts: ~ogIyrnin liioi)' iooNlf voilutl 01 uillaly GlIechoIamines and YMA
PHARMACOKINETICS
1Al1ft: 1- 3 min sublingua ~ 2- Smin buccal; 4O-fIO min trarudtnnal pa\(h
ADVERSE EFFECTS
The ad'Ierst tffrru of nitrogl)'l~rin are usua I~ ",Kliov.J scularin naMe and rarely
life thlutming. kGJ!/If nitrogl)'l~rin an dibte c~lI'brall'ffitls, he.d.ld1~ is <I
tommon side effect and may be 1I"Iert'.lXasion.lly, tilt Yl'IIOUS dilation caus~d
by nilrogl)'Ctrin prodJm Itfln tKh)'C<lldi.J. Somt hukh call' pKll'idm PII'Ilribe beta-adrmergic bIoc:ker to diminish this undtsirable inclus~ in h~an
I<lte. M.O)' 01 tilt side tffrcts of nitroglyarin diminish afltl a few doSI's.
(ontlain diciltions: Nitroglymin should not be given to patitnll with prenisting hypottnsion or with high intrm.nial pll'SSUII' or he.d traumil. Drugs in
this cia" <I II' contr.indiut~d in pericaKiial tampon.dt <lnd COilStn.:tWf periurditis bK.iUII' tilt lItan unmt irKrulI' cardiac output to m.intain blood
PII'SSUlt whtn mod ibtion occur!. Sum ined-fl'le.1I' forms should not be 9il'l'n
to p.titnts with glaucoma becaus~ the)o may incrt'.tIt intr.O(uial pll'swre. DIohydlation 01 hl'POl'Olemia should be tollf(\ed before nitroqlyuorin is aclministtred:othtrw~, ltlious hypottruion may IHUIt
IIKlfluations.
lk>ibaVFood:Unknown
Asse ss ment
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345
Assessment
Alk the pIItitnt to b.wfly desaibt the location and rhilractl'l of ~in (USt
~in riling snit lor rapid ilsessmtnt) prior to and .Jltergil'ing nitrattl to
iI!eSS lor tilt mtnt of relid.
Trach tht patitnt, family. or mrgivrr how to monitor pul'S! ind blood
prt.IU .... EOIu"" the proptru,," and functionin9 of an)' 00 ......".,ipmtnt
obtained.
E"I<Iluare the r"ftd lor adjun<tive Ueatllll'llt with htalth nrt prO'lidfr lor
angina prMmion arod lfI'atment(c.<j. btta bkKkets,.Jspirin thtrapyl or
fUnhtr" c.rdiat nudiet.(Patirnts with unstable angina lOa)' rrquirr
adjuoctivr drug thtr"apy or definitiYf (olrdiac nudiet to dti. rmine the nffil
lor other trNtmtrlt option~)
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34 6
UnII4
To ~Ilay polSiblt .Me!)" ttil(h tilt patient the rationalt for all fqUipment
Tilt patitnt should be .ble to state tilt 'tillOn lor drug;,ppropMt doll'
.nd sch~dJling;what ad~ ~IKtI to obSI'rw lor and wht n to ft'IIOI"I;
fquipmtnt IIffiird as appropriateand how to lIII' that fquipmtm; il nd tilt
requi'M length 01 mrdic.Jtion th~raP\' nerrll'd with i OY spKial instructions
ft'9arding renewing or continuing prrscription ilappropriat~ .
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Cho,lt. n
347
I Atenolol (Tenormm)
tial dosn.
Pregnancy c.JItgory D
r PHARMACOKINET1CS
Onstt: I h
ADVERSE EFFECTS
Being , urdio~~ bela,...Jdll'llt rgic blocker, atenolol has few ,.M~ dIms ontht lung. Tilt mOil frequently Il'pOned adYers~ tfftcts of umdol ind~ flligut. ~,knffi, br"lywdia"nd hypoll'llYon.
Contraindi u tions: ~u~ atenolol,lows lINn ratt, it 5/tould not be md in
pat ienll with IM'rt br, clyuroia,AV hu n block, wdiogrnic ,hock,or derornptnm!d hean I, ilurt. Out to it! modilation dI~lI, it is rontraindiuted in j)atiMts with ~ hypolension.
INTERAalONS
Drug-Orug: Uinarllenl UII' with calcium cilannfl blockers may [MOO in n<nMo
ur <iac 5l.WffSlion.lisf with!igoxin may slow AV conductiCIl, iYlilglo ' - '
twd.(lOOIItrl Ull'1I atenolol w1th oWr anut,pHtenli"ll"l may ~ in addtiw
h)"pOlel.sion. Antir:hoIilli'lr;co; may CiIU\t dfcrNIfd almplion 11001 the GI tr.I:l
li b Tests:A1PnOIoI may inuru valuiol II the foOowilg bbod tflll: uric add, iPds,
pcKaIlillll,O!alirine.and mnuciNrmbody.
HerlwliFood: Unknown
Treatmrnt of Overdose: Tilt mOIl ~riouSS)'lllplOm, of atenolol O"t'l'rdo~ al\'
hypotm,ion , nd bradyurdia. Atropine or ilOprolell'llol mil)' be UI~d 10 re.... rs~ ~.adya,di . Al"l'nolol Gin be ~mo....d from lilt <~sltmic ,irr:ulo~on by
h~moo:ialysi~
~k: 2--4 h
MYOCARDIAllNFARCTION
H earl attacks or m)'OQlrdial inlarrt ions(Mls) are responsible for a
substantial number of deaths each year. Some patients die
before reaching a medical facility for treatment, and many
others die within 48 hours following the initial Ml. Clearly,
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34 8
..
Prototype Drug
ADVERSE EFFECTS
ADMINISTRATION ALERTS
PHARMACOKINETICS
Q,SfI: 3Q-60 min (2- 3 h lUSuined reiNlI')
!'fialt<! 10 v. lOdilation: lIt.ldaclIt, diuinffi, and ~dtma of the anlde and f~l Abrupl withdraw.1 may pmipilate an acUlf . ngillill episod~.
Contraindications: Ililtimm iscOIluaindicattd in patienuwilh AV hun bloc:k,
lick si!lll S)"ndrom~, II"I!'fl' hypotem ion, or ble~dill9 a_rysm, or thOl~ Undelgoing inlracranial SU"lff1. This drug mould be UIed with ('lIIion in patiloms
with rPnal or Iv.,.uic imp>illlll'nl.
INTERACTIONS
ofdiliazflll.
Trtatnlent of Ovtrdole: All\lpine ot isopmttltnol may be used to reve~
br.dyuidia caUSt by dihiazem OYerdoSl'. HypoTension may be R'"I'med by. vaSOpft'llOl wch as dopamine or dobutamine. Cakium chloride can be adminisTt li'd by!low IV push 10 IM'III' hypotemion or lItan bIoc:k induced by (C8s.
Rmr II MyMfihrgR for ~ MnJrtg l'reiI fools spt(itt 111M ItrJ9.
progress after an MI. Tablf 25.2 describes some of these important laboraTOry values.
Early diagnosis of MI, and prompt initiation of pharmaCOTherapy, can significantly reduce mortality and The longTerm disability associated with MI. The pharmacologic
goals for treating a patifnt with an acute MI arf as follows:
Restore blood supply (reperfusion) to the damaged
myocardium as quickly as possible through the use of
thrombolytics.
Reduce myocardial oX}'gfn demand with organic
nitraTes, beTa blockfrs, or CCBs to prevent additional
infarctions.
Control or prevent MI-associated dysrhythmias with
beta blockers or other antidysrhythmics.
Reduce posT-MI mortality with aspirin, beTa blockers,
and ACE inhibitors.
Manage st'Vfre MI pain and associated anxieTy with
narcotic analgesics.
THROMBOlYTICS
In treating MI, thrombolytic thfrapy is administered to dissolve
dots obstructing the coronary arteries, thus restoring circulation to thf myocardium. Dosages and descriptions of the various thrombolytics are g ivt'n in chapTer27 on page 38JOC> .
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349
Duration of Elevation
No<mai Range
0: (ura~~ kina~)
Hh
lH4h
HtIa)'S
ESIt (~rythrocyl~
Itdimmlation rat~)
fim""
~alWft'ks
,,,,,,,
_.,
LDH(lirut~
male\: 1- 11 mmihr
frlllil!'l:l - ZOmm/lv
dU"ation of Itrt'lSll'SpoIIIf
fu~ng:80-1l0 m91dl
8- 72h
Hcb)'S
8- HtIa)'S
SO- ISOuriuA
m)'C9obin
Hh
Hh
HtIa)'S
HSll9lmL
troporinl
Hh
2H6h
7-10tla)"i
llm(gll.
troporin T
Hh
2H6h
10- HtIa)"i
0.01-<1.1 n9fI.
f~""
l -7t1a)"i
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350
Sy""'"'
Right
coronary
"""
Right
vootricle- - - II
Inlerior vena
- --I"'i
~.
Superior
~
~
Lei! coronary
"oy
Right _
__
I \, ,- - Leltvenlride
"""'ride
Inferior V'Ilna
""
Flgure25.2 Blockage and reperfuslon following myocardial Infarction: (a) blockage of left coronary artery with myocardial
I",hemla;(b) Infusion of thrombolytlcs;(cj blood supply returning to myocardlum;(d) thrombus dissolving and I",hemla clearing
Source Rgurf'S (a) aM (e): MlJIv!hm et a1. Hu man Olse.lses: A Systematic AppfOilCh, 6th f!d., Cl lOO6,p. 105. /lepffiroo by pronI15JooofPf!(HlOO
Educarlon, Inc., Uppff SaddkRlver, NJ.
NITRATES
The value of organic nitrates in treating angina was discussed
in Section 25.6. Nitrates have additional uses in the patient
with a suspected MI. At the initial onset of chest pain, sub(in gual nitroglycerin is administered to assist in the diagnosis,
and lhr~~ du",," may b., lak"" 5 mi"nl<:>c apart Pain lhall'~r
sists 5 to 10 minutes after the initial dose may indicate an MI,
and the patient should seek immediate medical assistance.
Patients with persis tent pain, heart failure, or severe hypertt'nsion may receive IV nitroglycerin for 24 hours following the onset of pain. The arterial and venous dilation
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BETA-ADRENERGIC BLOCKERS
Beta blocken; reduce myocardial oxygen demand, which is
critical for patients experiencing a recent MI. In addition,
they slow impulse conduction through the heart, thereby
I Reteplase (RetavaseJ
Pharmacologic ( la ll: ThcomOOlytic
ADVERSE EFFECTS
minogen 10 fOflll plismin. Plismin thtn dtgr.dn the fibrin mwix of tIlrombi.
likt othft dlUJl in 1M elm. rl'lepUlI' Wluld lit giftn as lOOIlas pmilIr after
tile omtt of MJ Iymptol'l'll. Adminilterl'd b,- rI bolus, it UIUlIIy ~u within 20
minuttl.AlKood bcM ,uy bt injttd 30 mioulIeS after t:M fin!, if ~ to
dmthfthrombus.AfterdJulot hal bem dissolwd. tlwrapy with i1fp.lrinOf in
iltematn.r anticoagulant ~ itIrttd 10 p~1 iddition.Jl dol! from Iooning.
~~ may bt IIStd of-l.1btllO ~at I<utt irld dHonic dttp \lein \h,ombo-
~itibirmwlprocku~iIkiIiw.nicDaglHnl~~ndinm.Jlf1llt
ADMINISTRATION ALfRTS
ItmJnstiMt !he drug imlnl'dial.tly prio, to lISt with dilutnl prtMded by
rNnuf~bet; Iwirll1lmil-do not shih.
Do not 9M iny othtrdrug limultaneously thlOugh tilt samt rllint.
Rtttp&.se ind 1IePirin i~ incompatible Md mUll nMr bt <Ombintd in
!be lilnl' soIInion.
PHARMACOKINETICS
Duration: UMnOWO
sup pressing dysrhythmias. which are se rious and so m etim es fatal compliotio ns following an MI. Research has
clearly demonstraled thai beta blockers ca n reduce MI _
associated 1Il0rtaiityifthey are administered within 8 hours
ofMI onset. These drugs may initiaUybe administered IV in
the hospital, and laler switched to oral d os ing for home
therapy. Unless contraindicated, beta-bJO(ker therapy continues for the remainder of the patient's life. For patients
unable to tolera te beta blockers, calcium channel blockers
are an alternative.
LibraryPirate
"'.....,
P~nincy~tgory (
Onwt: Immtdiate
Pu k:Unkoown
I!.tIflife: B-16 min
INTERACTIONS
Dn..IrI)uo;ConarIffftt tllffapywilll iSPiM.~15,Jnd pWtMt
PAIN MANAGEMENT
The pain associated with an M l ca n be debilitating. Pain
contlol is essen tial to ensure palient comfort and to leduce
sIres.;. Opioids such as morphi ne s ulfate or fen tanyl are
given to ease extreme pain and to sedale the anxious patient Pharmacology of the opioids was presented in
chapter 1SOO.
352
25.4
25.5
Betaadrenergic blockers relieve anginal pain bydecreasing the oxygen demands on the heart. They are drugs of
choice for prophylaxis of stable angina.
25.7
Angina pectoris is the narrowing of a coronary artery, resuiting in a lack of sufficient oxygen to the heart muscle.
characteristic symptom, although some forms of angina
do not cause pain.
25J
25.6
25.8
TI,.,
.,~rly
<!iagll..,,;is uf
lJ 'yuu",Ji~1
illfuLtiUll
ill~r.,,,,,,,
chances of survival. Early pharmacotherapy with anti dysrhythmics targeted reducing the workload on the
heart and inhibiting fataL dysrhythmias.
25.9
The patient is being discharged with nitroglycerin (Nltro stat). Patient education would include the instruction s:
1. "SwaUow 3 tablets immediately for pain and call 91 e
2. Put one tablet wKleryour tongue for chest pain. If pain
does not subside, you may repeat in 5 minutes, taking
no more than three tablets."
3. "0.11 your physici~n when ~u h~ve chest pain. He will
teU you how many IlIblets to take."
4. "Pbce three tablets under your tongue and call 91 I."
A prililllry mechanism of action that makes nitrntes useful for a pat ient with angina indudes:
I. they increase hrurt rate to increase cardiac output.
2. they increase preload so more blood isavail.1bleto be
pumped to the circulatory system
3. they increase contracrility so the heart works more
effectively.
4. they decrruse alterload so the workload of the heart is
da-reased.
The nurse recognizes that the mechanism of action of
beta -adrenergic blockers in the treatment of angina is:
I. slowed hean rate and decreased oontracrility.
2. increased contracrility and heart rnte.
3. relaxation of arterial and venous smooth muscle.
4. decreased peripheral resistance.
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II
PlIl the (ollowlng nursIng tnterventJons In order (or a pa tient who is experiencing chest pain.
I. Administer nitroglycerin sublingually.
2. Assessheart rate and blood pre;.sure.
3. Assess the l0C3tion. quality, and intensity of pain.
4. Document interventions and outcomes.
1:1
(,,"pt .. lS
l5J
3. Apatient with chest pain has been giwn ttle calcium chanOO
blocUrdiltinml (Canli~m) tVror a Ile3rt l'lIlo!of 118 bf:Iu
per minute. Blood pn:ssurt at thl$ u~ Is 100160 mmHg.
Wllal pl'Kllulions should the nunc' taker
Su Apptndix D for allj"'UJ and rlltio,mlts for all actjvjl~$.
r-==:-~'----,
EXPlORE ~
tI.jttI~ 1<;)QIr
-lIIlJII b
,new ~ arcI
ttClO:--$\JIt Pl'\ldlte
orOIe c/llplBI
r9:IIllCH.
QUI:ISIions.
~ _I~ !rI(I
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Chapter 26
Drugs for Dysrhythmias
DRUGS AT A GLANCE
LEARNING OUTCOMES
JlljfJS9
BETA-ADRENERGIC ANTAGONISTS/BLOCKERS
""J6!
""'~
POTASSIUM CHANNEL BLOCKERS
JUjtJ6J
{J!lIJt365
6.
8. Know representative drug examples for each of the drug classes listed
in Drugs at a Glance, and explain their mechanism s of action, primary
actions,and Important adverse effects.
9. Use the nursing process to care for patients receiving drug therapy for
dysrhythmias.
KEY TERMS
action polrntial JY.XJ1155
auioventri(ular bundle pJt 356
atrioventrkular lAY) node jJQI}l J56
automaticity f<!(jt1S6
bundle branchu {XIgt 156
calcium ion mannel {XJIJtJ58
rardioversion/drfibrillation paqt 157
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depolariution jX1Jt 1~
dysrhythmin f'JIIt 155
edopidoci/pa{rmakers
pogt 156
fl~drorardiogram (ECG)
f'JIIt 156
fibrillation pt.TJelSS
impla ntablf cardi overter defi bri nators (K DJ
pu;em
polarized fl!9eJ~
potomium ion mannfl f'JIIt 158
Purkinjefibers pi1I}t 156
refradory period fl!gt 158
~noatrial(SA)nodf ;we156
~nulrhythm fl!gtl56
TABLE 26.1
355
Stroke
Diabetes mellitus
Congestive heart failure
PHARMFACT5
Oysrhythmias
[lysrhythmias JIl' It"\jIOffiible for mOlt' than 44,000 dutm n(h 'ft.lr.
!erial dymythmill O(Qlr IIIOIl' IOmmonly in mt n tlun in worun.
T~ ilKidtn~ of uri.rl ~rhythmias ilKll'a~ with age. The)o Jifr(t
<05%of thOSl' Jged 15 to 35.
1.5% ofthost up to Jge 60.
9l(i of thoW' OVl'r age 75.
IOOut 15% ohtrous O(Qlr in p-atitnts with atriJI dysrhythmias.
AIaI9t majori\)' of !Udden (ardiac dNths all' btlil'wd to ~caus~ b)'
Y~mrKular dyyhythmiol~
Typesof Oysrhythmias
Name of Dysrhythml.
Desc~pt1on
Atrioll or I'tntrirularoo)'Qldia
Rapid lItan beat gruttrtlun 100 beau ptrminut~ innllu;m!!riIwmdlyurdioi ~ mort' W'l'ous
thin atrial udlyurdiol
Aui.ol or I'!'ntrirularflutttr
Ripid,rr<]Ular heartbe~ts; nay ra~ betWffil 200-300 beau/ min; atrial may rtqUir~ tll'atmtnl but is
not uswly lau~ I'tntrirularftu1itr ~RS jmm~tt trNtlllffit
Aui.ol or I'tntrirularfibrillati:HI
Hurt bIodr:
'kr} rapid, !JI(oordillilltd tNl~ compltt~ disorIFonization 01 rh)"ltm Il'IUhing in lad; of .!ltqualt
wdia>c: (ontrinion; II'qu rtl irnrntdialt trutmm
Area 01 lIOTIUIT"Idunion in tit m)'CQ'lli!m; may be partial or aHIlpletr; dassifitd as first, W'(ond, or
thirtl~
An utra ben ofttn ori9illil"ing fKrn J !OIItt other than the SA nodt; not normally W'l"iouI un~ ~
O(Qn in high fi"equtnt:,
SIowlltanbei~ 1m than 6) bNil ptr miMt; may r~R ' pilmlaur
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356
alrial plllhways
"'"'" -------rTt~
tnl"rvootricUar
..,,~
c::,~----cr-T-- AV junction
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Internodal atrial
conduction pathways
\'6<--------';--------
Bunda brar.chw;
Puoonje network
Atrial
depoiariZlOtion
V""tricuia,
,epoIa riZlOtion
V""tria.ola,
depolarization
,
I
I
02
'-----v---'
'---.--'
Q"
,..
I
"
26.4 NonpharmacologicTherapv
of Oysrhythmias
The therapeutic goals of antidysrhythmic pharmacotherapy
are to prevent or terminate dysrhytlunias in order to reduce
the risks of sudden death, stroke, or other complications re~
sulting from the disease. Because these drugs can cause serious adverse effects, antidysrhythmics are normally reserved
for patients experiencing symptoms of dysrhythmia or for
those whose condition cannot be controlled by other
means. Treating asymptomatic dysrhythmias with medications provides Little or no benefit to the patient. Health care
providers use several nonpharmacologic strategies to eliminate dysrhytlunias.
The more serious types of dysrhythmias are corrected
through electrical shock of the heart, with treatments such
as elective cardiovrnion and drfibri llat ion. The electrical shock
momentarily stops all electrical impulses in the heart, both
normal and abnormal. The tempof3ry cessation of electri-
LibraryPirate
~ norm~1
SiOllS rhythm.
358
is necessary for Wlderstanding drug mechanisms. Action potentials occur in both neurons and cardiac muscle cells due to
differences in the concentration of certain ions found imide
and outside the cell. Under resting conditiom, Na+ and 0.1+
are found in higher concentrations outside m)Ucardiai cells,
and K+ is fOWld in higher ooncentrntion inside these cells.
These imbalances are, in part, responsible for the slight negative charge (80 to 90 mY) imide a myocanlial cell membrane
relative 10 the outside of the membrane. A cell having this negative membrane potential is called pdarim:!.
An action potential begins when .odium im mannel. located in
the plasma membrane open and Na+ rushes into the cell producing a rapid depolarization, or loss of membrane potential.
Duringthis period,CaH also enters the cell through calciumim
mannels, although the infiu.'I: isslower than that of sodium. The
entry of Ca H into the cells is a signal for the release of addi tional intracellular calciwn that is held in storage inside the
sarcoplasmic reticulwn.lt is this large increase in intracellular
Ca H that is respomibleforthecontraction of cardiac muscle.
During depolarization, the inside of the plasma membrane temporarily reverse; its charge, becoming positive. The
cell returns to its polarized state by the renlOval of Na + from
thecell via the sodium pump and movementofK + back into
the cell through potassium ionmannrls.ln cells located in the SA
and AV nodes, it is the influx of CaH, rather than Na +, that
generates the rapid depolarization of the membrane.
Although it may seem complicated to learn the different
ions involved in an act ion potential, understanding the
process is very important to canliac pharmacology. Blocking potassium, sodium, or cakiwn ion channels is the primary phannacologic strategy used to prevent or terminate
dysrhythmias. ~ Figure 26.3 illustrates the flow of ions during the action potential.
The pwnping action of the heart requires alternating periods of contraction and relaxation. There is a brief period
of time following depohlrization, and most of repolarization, during which the cell cannot initiate another action
potential. This time, known as the rrfillctory period, ensures
Cl aas II
Beta-adrenergic blocker
Propranolol
CII M IV
Calcium channel blockers
' Verapamil
+20mV
OmV
CI I
Sodium channel
........
Procainamide
(b) Depolarization
Sodium and calcium
channel gates open
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(e) Repotarization
Potassium channel
gates open
drugs a(t by al tering specifi c elec trophysiologic properties ofthe heart. Theydo this through two basic mechanisms: blocking (\ow through ion channels
(oonduaion) or altering autonomic act ivity (automaticity).
Antidysrhythmic drugs are grouped acoording to the stage
in which tbeyaffect the action potential. These drugs fall into
four primaryd asses, referred toasdasses [, II , [lI,a nd [V,and
a fifth group that indudes In iso::ellaneousdrugs not ading by
oneo(the first (our m('l;hanisms. The five categories of antidysrhythmics and their medu.nisrm are listed in Table 26.2.
The use of antidysrhythmic drugs has significantly declined in recent years. Resear(h studies holve found that the
use of antidysrh yt hmic medications for prophylaxis can actuall y ;ncreast: patient mortality. This is because there is a
narrow margin between a thel'1lpeutk effec t and a toxic eff<>eT with ([nIp? ThM ~ffU.T (.Mtlbc rhythm. Thl'}' hnvi! th i!
ability nO! only tocorrtCl dysrhythmias but also to worsen or
even create new dysrhythmia s. Th ese prod ysrhythmic effects
have resulted in less use of drugs in class I and increased use
of drugs in class II and dass III (specifically, amiodarone).
Another reason for the d ecline in antid ysrhythmic drug
use is the success of nonphannaco[ogic techniques. Research
has demonstraled thaI catheter ablation and implantable
defibrillators are more suw.'s.sful in nlOlnaging certain types
o f dysrhythmia s tha n is the prophylactic useof med ications.
TABLE 26.2
Classlficatton of Ant.dysrhythmics
am
"'0'"
hdtcatlons
IA ~"lIfOOIirwride
IBmmplt;lidoulnt
AtrialfklutJandftJrillatlorl.~hmla.
~ Sodl.r"ham@l
111.1
_...
IC ~mplt:flt{iinide
fHMwn dIirJJ@llIIocbrseuJ!1llt:
,,",pmII
-.,-.,-"
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359
tIlIJioUr dyIr\Iythmlal
Adverse Effects
PfWNmide (Proanbid)
quinicint glUUI!I.Jte
quinicine Mlflte
"'-
kiM fprouinamjdpl
mmetine (Mexitil)
",,,,,, )
(Mdgg'oo
ma6gn,JQ!
[phrnttoinl
lIfGIinide (bmbowf)
prtipifmone (Rythmol)
HIlIoIoI (BrlYibkx)
Aqr!IuW!o!k.!armcmpasm SiMll5-.ioImoo
M!d~ .wp!'N!.msf 1M drug klbrmllyvmhdr.wm
MnIodirttlt(Cofdmne,hctrOllt)
doiecilidt (lil:osyn)
Itontdaront (Mu~q)
PiI;400mgljd
bltilide (Cl:lMrt)
KIfIIiri"lQ./MO,mQ
May pn:dKt IlfW !MrtrytbmiH q W9rV!l aisljng
SM' hyootmslon. bradyooia QrlM!O!!i.J ..Ue
syndrome [ampQ!'tt)
[dofelilidsl (!(S
!I'jrjty m"rtiIdr1
.!!!Poedtm'
PiI;240--480 mg/day
MISCELlANEOUS ANTIOVSRHYTHMICS
"'''''')
""
"'"
'"
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I Procalnamlde (Procanbld)
Class: Antidysrhythmic
PHARMACOKINETICS (PO)
Onset: lOmin
ADVERSE EFFECTS
/lausu, vomiting, <Ibdominal pain, hypotension, and htadache aft' common
during procainamidt therapy. High doses m.J)' prod~CNS effKIIsuch ,sconfusion or psythasis.like aII amidysrllythmic: drugs. procain.l midt has t~ ability
to product ntW dysrhythmiu or worstn existing ones. Alupus~ike syndrome
mayocwr in ]0% to SO% of p-atitnll taking t~drug 1M'! a )'Nr.
Conuaindi{itions: Procainamidt is comraindicaled in patifnlS with {omplete
AV block, 1M' ft' CH F, blood dysera sias, and m)'ilthenia gravis.
INTERACTIONS
DIII!rDIII!I:AIkI.ft(;l(ljiac~fffK6mayoccurff~~
HerbaVFood: lInknown
lINIment of OYl'rdOSf: Supporti\'l' ireaUllmt is targ~ted to Ie"I'l'lSing hypol~nsion with mopl\'SlOlS and pft"lmting or tft'uing prouinamidt-induced
dylrhythmiotl..
It!ftrrc M)Nrmlfl9l1!lbrQNulllfll} Pnxm fOOlllpf(lkrcllrti~
~k:l - 1.Sh
Halflife:lh
Duration: 1 h (8 h IUSiaintd ft'1e, 1t)
Assessme nt
Baseline assf51ment priort o admini strat ion:
Undtrstand th~ ft'ason t~ drug has 1ln prt'I{ribed in ordtr 10 mfls for
thtra ptUlic: ~1I"Is (t. g., atrial, Vl'mricular dysrlrylhmiasl.
Obtain a complete htakh history including urdiovaswlar (including
preYious dysrhythmias, HTN, Ml,hean fa~ull'),ancl the possibility of
pregnancy. Obtain a drug history induding allerg~~ {um'nt pltSuipbon and
OK drugs, herbal pR'p<lration~ <Ind akohol UI~. ~ aim to possible drug
int..... tions.
Obtain ba!!'ifl!'wt9l~ vital signs (epKially BP and pul!!'), KG (ral~and
rIryIhm),caroiar: monitoring (such aSlllrdiac rulpul if appropriale),and brNth
soo.nIs. AsS!'-u forlocatiln and charan"!amount of rotm.t, ff pltSenl
E'f<Iluateappropriatt laboratory findi~, ~Ie{trolyte,tsp((iotl~ pomsium
1e1'l'l,ll'n<l1 and liYrr function studies,and lipid profilel.
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362
W~igh the patient d!ii)o JOO report a weight gain or loll of 1 kg or more in ~
2HlOu, period. Continue to oIIll'!S for ~IN, noting Ioc.tion <l nd {harXler.
(Daily weight ~.n mu,ate measurr of lkJid !tI1UI.nd tl~es into x{ount
intake,OUIpu~and illlfnsible IosItS.Wrilht gain 0' edema may inditate
advtl"ll' drug tifrmor...,rsening mdio\\Jl{ular distase promlfl.)
HiYe the patient weigh !elf d.Jii)o, iduli)o ~t the ~m~ tim~ of d8;,.nd
It'(ord weig ht along with pulst mealUrrmenll.H.we tht patitm It'pon a
weight loll 0' ljiIin 01 mort' than I kg (appl"Olimately 21b) in a 2+hou,
period.
Monitor for blt'ath I01IIds <I nd lINn sounds (e.g. iKrming dyspnea or posltJ"al
fIO(tumal dyspnea, ralts or"(fol{kIt( il lurqs, frothy pink ~nged sputum.
1IlIIl1IUr; or alra hean IOUM) alii II'por! immed.J~ UrKreaIDg lung
rongestion or _ or \\OJBI' ning hean munnur; may ildicate inpending lINn
lam. Potassiun-<hannel bIodctrs an' .lIOriited with pJntonaI)' toxi:~)
Teol{h the patient to It'pon any vision {hanges promptly and to maintlin
It'gula, eyt euminations.
Teol{h the patient 01 importln{~ to 'NUr protffiiYe {lathing and <l PPty
u",-rm-, "'IIuLlrt, during "",iud> of ,uo ~'po>Ure.
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363
The patifmandlor family should be ilb~ to IIUt tIM< ~alOn for drug;
approp.wlt Om and s<lM<ru~ng;wh.n adYl'rll' efiKl! 10 oblffi'l' for and
wlM<n to rtport;equipment nffiItd ill apprnpriat~ ud how to lI!e that
tquipmem;and tIM< rtqJi~ Itngth of lTIfdication thtrapy nmled with
any spKial illltnKtiolll ~ardin9 renewing or mminuing presc:ription as
approp.wtt.
Ttl(h tht patitm to ta~ drugs" M'fIty 'pa{td apan iI> poI~bIt and not
to doublt 0011' if iI 0011' is misstd
Tmh tht patitm not to dilcontinue tIM< meditation abruptly and to ull the
health cart pra<ider if the patient is unabit to take meditation for mo~
thil n 1 day due 10 iIInes.
The patient is able 10 diswlI appropriate dosing and aclminiltmiln Iftds.
<IlIi"lfImi.tugs (e4.(fId!m(hDnMlIlkKtm~
BETA-ADRENERGIC
ANTAGONISTS/BLOCKERS (CLASS II)
Beta-adrenergic antagonists are widely used for cardiovascular disorders, including hypertension, MI, heart failure,
and dysrhythmias. Their ability to slow the heart rate and
conduction velocity can suppress several types of dysrhythmias. The beta blockers are listed in Table 26.3.
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is in
364
UnII 4 'It"
Plf90ancy catrgory (
PHARMACOKINETICS (POI
il"lset05- 1~
ADVERSE EFFECTS
Common
rfferu 01 propranolol indud~ fatigur, hy~t~nsion, and
bradycallfia. Because of th~ . biliQ of prop'. noloIlO llow ~ hun rar~ patirnu
with ~rious ca rdi.Jc: dilordtrs SIKh as heart fa iuft' must lit cartfally moniiOll'd
Adftrse rlFeru sum as diminished libido and impotencr may ~!Uk in nonadheft'llcr in male p.titms. Propranolol ~ould br ust<! caUlioully in diabttiu dur
to irs hypJglyo:rmic ell"Kts and beuusr it m.y ' 1IY!k' the sym~lOms of hypoglyo:emia as the .drenrrgic "fight-or-flight' to hypogl)l:emia i; blocked. This
drug ~ould br used with c. ution in patitnts with Il'dicrd Il'oal rulpIJ~ btciuse
thedrug II\a)' cumuliII' 10 IOl ic ~Is in !he blood ind cause dy!;rhyrhmias.
Contrai nd ications: BeulM 01 iu dtpressM.- ell"Kts on the he. It propranolol is
comraindicated in patients with cardiogrnic !hock, sinus bradprdia, greater
than firstgll'l' heart block, and lINn f.iull'. i!euuse it constricts smooth
IIIJI(Ie in the airwa)'l,!he drug is conmindicattd in patients with (01'0 or
Uthlllil.
.amse
INTERACTIONS
1Wg- 1Wg:(0IKII"1m adrnirislBion with oIhfr beta ~m may p-OOUCf
~fff,m IIllMhear~ i!nd toi)'lalooorhypot!Mion Ioa)'fffit.SfatM
both pr~ i!nd 00l1li dIDleI blockm SUpplll! ~f!hl rormr:lii)',
<roaIIIMI U!l' loa)' INdIO ad!iIiI'f tfiHtjurdia. PhrnoIhialilll5 can id:Ito the
h)polfllliw ! 1I"!m 01 propr;InoIoI. Propraoolollhould 001 be givfn wiOin 1 WI'fks of
an MAO inhlJilor, as ~'/!ft bradycardia and hypotenlion (OWd fMlAl.lN of !!IIao:d
or ar:ucids (0II1aRn9 .luminllll h)'droDde IJ!I wil !low 1M abIorpJi..- of
propranoIoIlnd Il"IIo.n its therapMc III"I'ffi. AOOIioistmioro of blli ...:lrrnergk
agonisn sudo as aIbuteroIlPrOl'Hli~ wil.nugonizf llot aaionI of JroIIOfIOIoI.
Lab TfSU: PrDp"aoolol may gi~a fw O:IMI' for uriy;y ~
IkorbaVFoo:J: Untnown
T~tment of Olerdou: Tll'atment is urgeted
~asopressors. .nd b~)'Urdia with atropilll'
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siwn channel blockers slow the heart rate, resulting in serious bradycardia and possible hypotension. The>e adverse effects occur in a significant nwnber of patients. These agenlS
can wo~n dysrhythmias, especially following the first few
doses. Older adults with preexisting ht'art failure must bt'
carefully monitored because they are particularly at risk for
adverse cardiac effects of potassiwn channel blockers.
Amiodaront' can produce pulmonary toxicity in a signif~
icant number of patients. Sotalol and ibutilidecan produce
torsades de pointes, a type of ventricular tachycardia that
can become rapidly fatal if not recognized and treated.
Treatmt'nt of torsades de pointes includes IV magnesium
".Hal" ur l'ul"",,iuJH dduriu".
In 2009, a nt'W potassium channel blocker was approved.
Dronedaront' (Multaq) is chemically similar to amiodarone
but is claimed to have a reduced incidence of adverse effects.
Like sotalol, dronedarone has multiple actions on the heart.
Dronedaront' is approved for the treatment oi paroxystrurl
or persistent atrial fibrillation or flutter. The labt'ling in~
.,
36S
PHARMACOKINET1CS (PO I
Onll'l: 2- ) d to 1- 3\\'Ie
Iflk:l- lh
Halllife: I S- loo days
Duration: 10- 150 day;
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ADVERSE EFFECTS
The most .moos ~r ~t from amiodarolll' occurs in tilt lung.. wiIh tilt
drug (,lu,ing , pneulMnia~ikr ,yndrome.AmiotbrOlll' l1IiIy ako UUII' ~Iurrro
vision, rashr-s, pholosrnsitivity, naulI'a. wmiting. anorma. laligUl'. dilzilil'ss
and hypotr nsion. Becau,r Ih~ medication ~ concr ntrated b)' Cfltai nt~,ues and
has a p-oIonged haK-life,advrrll' rffts may ~ slow to ll'SoMo.
Contr.indic.tions: Amiodarolll' ~ contraindicaltd in patients with ~Il'
brad)'Uroia. caroiogfn ic shock, sick sinus syndromt .1I'ft1l' sinus node dysrunctio n, or thiro-dtgll't' AV bloci.
INTERACTI ONS
DrurOrug: AmiodilroM (l!I) io:KmII' SI'IIIm dgoIin IPwk by ~ mum as JO!oI.
Amioda1nlo gr~ H"IlarKts 1M acrionI of iIIlicOigWnI5: Thill,1M dolt of
warfotilllllll bf cut by ~ much iIIhiIIlLM wiIIl bm~""'I9i: ttIdM 0/
<.okiumdlanntll>lockm Il10)" ...... orw ..... ~"US 1ndy<a"b....... arrnI, .... 1fI
~A~ IIIi'f ilKfl'<ftpher:rytoin "'wI!!\ItO- to thrfffoid.
La b Tests:May iooUW' YilIII"I r.... 1M following tflt!: nudNr arlibod~ AU,.IST, MId
'ifI1IIl Aalinf p/IoIphalilf. T~
Herba liFood: LM wiIIl edilloKN may QIM an inoMIed rill; of hfpItoIOIidIy..\Iot
cao.~ an iIcrNIfd fffPCI of MTiod;IIOOf.
1IIi,
TIl'atmenl 01DYerdose: Tll'atmrnt d amiodarOlll' O'>'fflb~ is targeted to revtr\iog hypltension with lllsopmIOIJ, and bradyurdia with atropilll' or iIoprotell'noI.
III'ftr I!I M)MJ1l11rqKJ/ Alr Q MJrf/1I} I'rI:Jmj foots J{lKI/{ I!I ~ druiJ
"
,,,~
~
~
i"
-"-
Vtr'pifllll wu the lint eel.1'f.IIOWd by the FDA. The drug .eu by inhibiting tt.t
flow of ukium ions bolll into JII)'OUfdill uns itId in Yisrulir smooth musdt,
In tht Mart. this action ~'M mnduction 'fHKity and Slabifim ~hythm~
In tile 'lHStb"cakium (~nntl bIoWdt Iowtrs blood pmsu~ ~udng urdIK
workloid.Vtupamil Iiso dilatt'l tile (OJOIIi~ ~t'I, In .mon thit is impor\.lilt when 1M drug is uwd 10 trtal .ogin. (chapter 2S00j. Tlledrug is iYii.
a~ in oral, oral ~ndtd-ft'lu~,.nd
IfwI i10.o8taO.lmc~ml .
ADMINISTRATION ALERTS
Swlftow tht Cipwle whole: Do IIDt open Of .11ow pilitms to chew the
{oottllB.
For IV administration,impt<t the drug f1RPUJtion to makf WIt thf ~kJ.
tion is dw and (O(oriess.
PJ!9MJq cat~ (
ADVERSE EFFECTS
AdYtnteftects.~ gtntr.lly miOOf.OO indudt M.d.ldlf,mnllipation,.nd~
potellsion. &aIM tIipolmil un UIM bmlyumil, pititoo with hein f.ikJre
should ~umu'" monitored.
(ontraindimiom: V~pamil is mnlr.Jindiuttd ~ palitrJb with AV twrt
blod, sick sinus syndJOmt, snere h)'pottmion, 01 bletdiog 'Jlfllf)'Un, or !host
unciel9oiJ19 ~troKrinill SUJgtf)'.1Jse widl uUlion in patitntt with ~il 01 hepitic impairment.
INTERACTIONS
IN}-I:nqVmpnW IllS tIlf.t.ility to~ blood Inft! d Iiqollln (Di;t8:.
I.anoIIIn.lanoJlkapsl ,SiJKt digoin and ffiapimil botb !low mndrIctiDn throu9l tht
....,J
PHARMACOKINETICS (PO)
Onset. I-2 h
Ptod:: 30-90 min (4-i h tJ:ttnded '*~)
Half-lit.:l --! h
OUfition :1- 7 h PO (24 h eJ:ttnclfd releil!')
for Dysrhythmias
Two other drugs, adenosine (Adenocard, Adenoscan) and
digoxin (Digitek, lanoxin, lallOXicaps), are occasionally
w.ed to trea t specific d~rhythmias, but do not act by the
mechanisms previously described. These miscellaneous
agents are listed in Table 26.3.
Adenosine (Adenocard, Adenoscan) is a naturallyocrurring nucleoside_ When given as a 1- to 2-second bolus IV in
jection, adenos ine terminates serious atrial tachycardia by
slowingcondudion through the AV node and decreasing automaticifyoftheSA node. Its primary indication isa ~pedfic
dysrhythmia known as paroxysmal supraventricular tachycardia (PSVf), for which it is a drug of choice. It is also used
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IIffrr IJJ IIfMlilrlfO fix , MnIIt9/'rrKm FoCIII SfHd* IJ) J1IIs lhJ
to assist in the diagnosis of coronary artery disease or dysrhythmias in patients wllo are unable to undergo an exercise
stress test. Al though dyspnea is common, adverse effects are
generally self-limiting because of its IO-second half-life.
Although digo:tin is primarily used to treal heart failure,
it is also prescribed for certain types of atria l dysrhythmias
due to its ability to decreaseautomaticifyofthe SA node and
slow conduction through the AV node. Because excessive
levels of digoxin can produce serious dysrhythmias, and interactions with other medica tions are common, patients
must be carefully monitored during therapy. Additional informat ion on the mechanism of action and the adverse effects of digoxin may be found in chapter 2400 , where this
drug is featured as a prototype cardiac gJycoside for heart
failure.
367
KEY CONCEPTS
The numbered key concepts provide 3 succinct summary of the important points from the corresponding numbered section
within the chapter. If any or these points are not clear, refer to the numbered section within the chapter for review.
26.1
26.2
The frequency of dysrhythmias in the population is difficult to predict because many patients experience no
symptoms. Persistent or severe dysrhythmias may be
lethal. Dysrhythmias are classified by the location (atrial
or ventricular) or type (flutter, fibrillation, or block) of
rhythm abllOrmality produced.
26.6
Antidysrhythmic drugs are classified by their me;;hanism of action, namely, classes i through N. The use of
antidysrhythmic drugs has been de;;lining.
26.7
Sodium channel blockers, the largest group of antidysrhythmics., act by slowing the rate of impulse conduction
across the heart.
26.1
26.9
263
The electrocardiograph may be used to rewrd electrophysiologic ewnts in the hean and to diagllOse dysrhythmias.
26.4
26.5 Changes in sodium and potassiwnlevelsgenerate theaction potential in myocardial cells. Depolarization occurs
when sodium (and calcium) rushes in; r<vOlariZlltion
occurs when sodium ions are removed and potassium
ions are restored inside the cell.
A type i diabetic on insulin reports that he takes propranolol (Inderal) for his hypertension. This raises a concern
and the nurse will teach the patient to check glucose levels more frequently because:
1. the beta blod:l>r can produce insulin resistance.
2. the I\m agents used together will increase the risk of
ketoacidosis.
3. proprallOlol will increase insulin requirements by
antagonizing the effects at the receptO[l;.
4. the beta blocl<Ercan mask symptoms of hypoglycemia.
When monitoring for therapeutic effe;;t of any antidysrhythmic agent, the nurse would be sure to assess:
1. pulse.
2. blood pressure.
3. drug level.
4. hourly urine output.
Because of itseffect on the heart, verapamil {Calan, CoveraHS, isoptin SR, Verelan} should be used with extra caution or is contraindicated in p<ltients with:
1. hypertension.
2. tachycardia
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3. heart failure.
4. angina.
368
II
UnII 4
. nd U,I""ry Syne<",
EXPLORE
~.-----,
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Chapter 27
Drugs for Coagulation
Disorders
DRUGS AT A GLANCE
LEARNING OUTCOMES
ANTICOAGULANTS
{XI/tJlJ
Parenteral Anticoagulants
pt1IJt313
Oral Anticoagulants
p1//t3l5
pt1IJt Jl6
modifiers.
o warflll1l1 (Coumodtl)
ANTIPlATELTDRUGS
fXJ1t3l';
ADPRectptotBlod:tu
pogtJ81
,...,
THROMBOLYTICS
O olrepw{Ar:rtwu>)
HEMOSTATICS
ptJ9IJU
poI}tJl1
f1II}tJlJ
p;lI)tJU
KEY TERMS
antkoagulant ptI9t m
antithrombin III (Xl9t m
doningfa<ton ptJ9t170
coagulation IUltllO
(oagulation~
~mbolus pajt
{XXJl170
fibrin {Xl9tllO
plasmin
fibrinogH
fibrinolysis
pla~n ptIIJt171
{XI/tJJO
pII(Jt 171
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pi1IJt 111
prothrombin
pIIIJt Hl
prothrombin actiwator
(J<JJt 1lIl
dvombin pogeJlO
lhrombocytopt~iI ptJIJtJl1
dvomboftwbolicdisorders pajl1l1
Ihrombolytio pqJlJ
IIvomlNs pi1Jt1l1
rissutplasmin09"l Mti,UOf (lPA) pqJ7!
_ Willebrand's ftase (lWDl pq Jl1
370
UnII4
Th<>(~ ,d""'.",ul.,.nd
",,,,,hwurk
lh~llrap'
bluuu
Vessel injury
Vessel spasm
Plalelets adhere
to injUry site and
aggregate 10
larm plug
Insoluble librin
slr&nds form and
coagulate
,. Flgure27.J Baslcstepslnhi'mostasls
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~Ul1'lill1"'nls~u lh~llh",y
371
PHARMFACTS
r1'IiI!Jf
""'' ,""
~
Clotting Disorders
von WiI~brJnd's disuSf (vWD) is th~ moll wmmon h~rI'ditary blffiling
damaged cells
f~orVlII.
Facto. X
(DVT).
J
PfoIhron-bin activalor (ProIhrornbOnase)
Moll' than 1S,000 peoplt in tilt United S!a!~ have hemophilia Aor B.
1----------- -------,
(t)
'''''''~.o _ Th......
Uve.
J :$
:
i
----1-+ Fibrinogen
PIIIsma
L ___________________
Injured vossel
....
Insoluble fib,..,
"
27 .3 Alterations of Hemostasis
creating thesl! clotting factors, patients with serious hepatic
impairment usually have abnormal coagulation.
lation must eventually be re5tored so that the tissue can resume normal activities. The process of clot removal is called
fibrinolysis. It is initiated within 24 to 48 hours of clot formation and continues lUltii the dot is dissolved.
Plasminogen
TIssuo plasminogon
Thrombolylico
~
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Clot breaking up
into "okIbie fragments
372
''''
Activittd dotting limt
Activittdpartial
thrombopiaSlil timt
(aPm
Blffiing~m~
Hrparin~Hi
()@sc:rlpllon
NormalValues
Significance
.-
h~than
"'.~
O.l--{l.7 intema~onal
0.4-1.1 intema~onal
un~"ml for
un~shnl for
l6istalKt
Platdetaull
Prothrombin timl' (PT)
Thron"bin ~m~
~ to monitorwarfilrin tlltropy
Used to ~!tS! for fibrilKl9ftl dtfitiffiq;
may iN' lISI'd to monitor ~ffta~\.I 01
heparin phi!Tllalllltropy
150,000- 350,000
Il-1S SKOnd!
htparin phirmiloihn"iP1
in a vessel, it often grows larger as more fibrin is added. Artrrial thrombi are particularly problematic because they deprive an area of adequate blooo flow, causing tissue
ischemia. Cessation of blood flow may result in infarction or
tissue death. This is the else in Mis and many CVAs.
Pieces of a thrombus may break off and travel through the
bloodstream to affect other vessels. A traveling dot is called
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Choplfl 21
373
Mechanism
H OME
&
COMMUNITY CONSIDERATIONS
:::::ft~'O"
An~plitelet
ThrOOlbolytic:
1Itm01iitic:
ANTICOAGULANTS
Anticoagulantsare drugs used to prolong bleeding time and
thereby prevent blood clots from forming. They are widely
used in the treatment of thromboembolic disease. Table 27.3
lists the primary anticoagulants.
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PARENTERAL ANTICOAGULANTS
The traditional drug of choice for parenteral anticoagulation is heparin. H eparin acts by enhancing actions of antithrombin III . Antith rombin III is a protein in plasma that
inactivates thrombin (and several other procoagulant enzymes) and inhibits coagulation. Within minutes after intravenous (IV) administration of heparin, the loss of activated
clotting factors prevents the formation of fibrin clots.
The heparin molecule has been shortened and modified
to create a newer class of drugs called lowmolec:ularwfight hfp"
arins( LMWHs). The mechanism of action of these agents is similar to that of heparin, except their inhibition is more
specific to active factor X (see Figure 27.2). LMWH s are parenteral anticoagulants that possess the same degree of anticoagulant activity as heparin but have several advantages.
Their duration of action is two to four times longer than
374
UnII4
TABLE 27.3
fondapamUl(Arillra)
Go)
Anticoagulants
Drug
litpam (HepIock)
Adverse Effects
~.".""''''~';~''''-''''
QMmi<I (fmdopaioox)
HemooIl.~
anaRh)'!aQj (b~rinl
' '.
Q warfaril (Ccunadinl
PO;2- 1511l9fday
fflJXiparin (Lamm)
tiIz.Jpamlinl'lOlltp)
anaRh)'!illis
OIRECTTHROMBIN INHIBITORS
ilgitrob.!O (Aw.II,tlo'muo)
l'I';lllKg~n
biYairudil(An9omax)
dtsirudin (lprivask)
Itpiodo ~OOan)
Imu: 10 IIKgl1!glmil)
XriOUI inlemal
~morrha~
WQri~rio
Hoopllrio and
l.t>w "''''''.......,
weight hepDrino
Lepirudio
that of heparin. The LMWHs also produce a more stable response than heparin; thus, fewer follow-up lab tests are
needed, and family members, caregivers, or the patient can
betrained to give the necessarySC injections at home. These
anticoagulants are less likely than heparin to cause thrombocytopenia. LMWHs have become the drugs of choice for
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I Heparin (Hep/ock)
PHARMACOKINETICS (SUBCUTANEOUS )
ADVERSE EFFECTS
Ab nomal M~tding may occur during IItpa rin tlltrapy. Should aPTI becollll' prolonged ortoxicity ~ obsmtd, stopping tilt infusion wilill'sult in dimini<htd
anticol9Jlanl oajyity within hours.
Contraindications: Heparin lhould not tie admini<w~d 10 pol~rns withac~
inlf mM blt~ding, blt~ding di<ordtll, s~re hyptrtmsion, II'Ctnt lrauna, inumarial htlllorrfrage,or bacterial moourtiiti<. Htparin~OOucrd throllbocytoptnia (HIT) i< a s~rious complication Ihat ocrurs in up to ~ of patitnt;
IiIking the drug.More s~re symptoms usua I~ apIINr aft~r S10 10 days d therapy, thIS, freqUtnl blood Iabor.llOry I~ting should tie coOOucttd during this ptriod.Athough thrombocytoptnia UlUally Itad! 10 HCffiiYt bl~~ding, HIT causes
the opposite efFect: an ;,eTNSt in aawll' thrombotrnbolic t"I~rnl. Tilt ~at~nl
may exptritoc~ lI'fious and t"I~n liflo-thlN1~ning thrombolis. Although the
half-life oflltparin i< britt it may IiIk~ <I ....,.~k afr~, tht drug i< disronhnUl'd for
p1atelt-.s 10 rompieleiy II'COV01l".
INTERACTIONS
Oral anocoagwnu, incluring warfarin, poreotiatf 1M action of
Mparill Drug\ thai inhlJil plat!ltl aglJfeg.!lioo, sudl ~ aspirin, incIcrnmIacil, atd
Drug-~rug:
"-
Ons~t: lO-Wmin
Pto.k: 1 h
Half li~: 90min
Duration:8- 12 h
ORAL ANTICOAGULANTS
The most commonly prescribed oral anticoagulant is warfarin (Coumadin). Warfarin acts by inhibiting the hepatic
synthesis of coagulation factors II, VII, IX, and X. Often, patients begin anticoagulation therapy with heparin and are
switched to wamrin when their condition stabilizes. When
transitioning, the tW() drugs are administered concurrently
for 2 to 3 days becaust warfarin takes several days to achieve
optimum effect.
Pentoxifylline (Trmtal ) is another oral anticoagulat that
works by a different mechanism than heparin. PentoxifyIline reduces the vlioosity of red blood cells and increases
their flexibility. It is given to increase the microcirculation in
patients with intermittent claudication.
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ANTIPlATElET DRUGS
Antiplatelet drugs cause an anticoagulant effect by intt'rfering with platt'let aggregation. Unlike the anticoagulants,
which are used primarily to prevent thrombosis in veins,
"
376
I Warfa ri n (Coumadm)
"
ADVERSE EFFECTS
The most Sfrious adYl'fII' rffKt of w.rfarin ~ ,bnann.!1 biffilifl!j. On d~(ontin
uation of lher,py. thr ,ntico'lJll.m oKtiity of warfarin may pell~t for up 10
10 days.
Contraindications: PnienlS with ~(~t trauma ctiYe internal bleeding.
b~rding dilOrdrn, intraocranial hemorffia,gt. 1t'I!'I'I' hypen~1io1l, bactt rial en
domdit~,or Il"I!'I'I' hepatic or renal impiinnenl4100ld 001 take warfarin.
INTERACTIONS
I)ug- l)ug: EnM~'II' prolHn bincing is Jl"lpon~bIt for nlrni'lOUl dr",--1Irug
inll'liK1ions, ilWdiIg an ifl(ffUd efIKr: of warfarin wfth aIutIoI, H'iA Ill, d~
5SRII and other ... idi>prf!Unt~, SifloidI,nibicOO and oonel. [00, 9 warli!rin
merapy, iIIf pititnt !hooId not taI;~ iIII'/ other prmiption or OK d!:ugI oolels
PHARMACOKINETICS (POI
Q,wU-7 dqs
PNk:0.5- 1diys
Assessment
Butline assessment prior to .dministration:
Undmtand the ~.!On lhe drug has heen p=ribed in order to ust'Ss for
lhe,apeutic efHcts (e.g, p~tion olthrombosis from developing wIltn
phlebitis is p~~d.
Obtain a (ompitte ht.lth his!ol)' induding urdmasrular (induding HTN.
MI. he.n f.iu,,).nd penphf,,1 ~al(ulardiINM' (induding
Ihrombophlebiris). ~r"ory (induding previous pulmonal)' rm boI ism),
oeurologic (indJding rtCem htad injury, (VA). lIfpatic or renal diIN ~
d.. brTP" fH'PIir uh, diu-all'. hy""" .... "'<IforoiPmi.o. ,nd Ihf. po< ~hility af
. ko .... lism or pfl'gn'IIC)'.Mkwornm of ~nrual.ge.bout length and
heavinessof uSlaI mrrntrual flow. Obtain. drug h~101)' inW:ling allergifl.
rurrflll pre!(ri~ion . nd OK drugs. he!bal pr~r"ion~ and .kohoi lM. ~
.~n 10 possible drug interoKtiorn.
Obtain bmlilll' wtight, vital signs, KG (~ ippropriilt'), .nd bre~h 1OUnds.
MIeSI for p~II'Ke, ~il)'.loution of angina. and br presefl(t of dylJllIN or
dies! piin. As II'!S e1urmitifl b, Iymptoms of thlOOlbophlfbitis (r.g, warmth,
swelling, lendenesl in (.Iii; posm...e Homan's sign).nd for Ioution .nd
maraoctl'l/,1IIOII1I of rdrm. ,if present
Enlunr .ppropriate laboralOry findings (e.g . <I PTT, aPT, .nd/or IIIR),
rompim blood(ount ((SC), ~nal .nd liYer function studifl, .nelial blood
galeS (ABGs) u.!pproprinl'"nd lipid profilei.
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Asseument
patient Ind
if tilt patient is on be1:iftSt or has ~rnile1l
mobility.l't'rform pusie ROM in JNtirms wIIo i~ unatw to ~rm oIctit
ROM.(Eirly ambulatioo "nd ROM plt'Otil~ ~ susis and tIvombosis
form.tion, itlsming the Mtd for "nticoagulant tbmpy.)
~ finge of motion fROM}
---\--
Assist the patient with ambuWtion postopeflllvtJ, liM ttach lICliYt ROM.
Tuch the p.itien~ firnil)', or Urt'i.jlvtf Ilow 10 ptrform p.ssivt IllM
e..1tists for p.it~rru wIIo _ ~nabIt' to ~ a(IM ROM.
prumn.
(Conrlnued)
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]78
Unit.
n.~ (.,d""'~uio,
SIN.
inslrUCltlle patiml to consul! the heillh C.Irt p""..idtr briM liking IIIJ
fII'W prtSCripbonOl Ole meditation, inWding herbal p!tIIoltions.
AsSt!.S ilf .IJIJS)'IJ\ptoms ofiwpariti1 (t.g..dirktning urine, light ordiymlored nook. ~d!y lkin,jaundicf of!der.io orskin,ilxlomioil pain rsprriIlly
in right upper ~dfim 1RUQ)) in ~tients rmiviog 0111 inticO.l!J!Linl
Wlipy. (Drug-induc:ed htpatiti1 is I possibk .dftBt' riFt of or.1
.micoagul.illl ttw,rapy.)
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in,
The patient should lit, Ible to state the rtuon lor drug;.pplOjlri.nedoSt
Ind S(he<kJiing; what advt!w tHfm to obsmoe for and wlltn III rtport;
tqUipment ~ as appropriate and how to 1M that fqIIipmtnt;and tIw
~ired ItrJgth of mediuOOn thfflp)' ~ with lOY sptci.ll instructions
rtgardiog II!'MWing 01 coJllinunJ presaiption as approprialt.
379
antiplatelet agents are used to prevent clot formation in arteries. The anti platelet agents are listed in Table 27.4.
27.6 Pharmacotherapy
with Antiplatelet Drugs
Platelets are a key ,omponent of hemostasis: too few
platelets or diminished platelet fundion can profou ndly in-
"n"
lJl(rt~~doItim t'!!!.!l!
" ~I
d~rnoIt (Pmantinl'j
1. ."'-_....., .;.
Adver'>!' Effects
blsmm !~m:inl
PO; 7, mgldly
praSlJllri (Effient)
tidopidinr (rKlid)
D~dzzinru,ponQInjtio~fite,
Hrnlorm~, Il'fomb!!n1!l1!!:!!ia
tirofib.Jn (Aggrilstat)
hyporen5ioo.b~ mioor/llttdllg
pentoxifylilll' (Trentalj
PO;400mgtid
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380
~ Prototype Drug
Glycoprotein li b/lila is an enzyme neces.saryfor platelet ass rega tion. These drugs are used to prevent thrombi in patients experiencing a recent MI, stroke, or percutaneous translwninal
coronary angioplasty ( PTCA). Although these drugs are the
most effecti~ antiplatelet agents, they are very expensive.
Another major disadvantage is thm they an be given only
by the IV route.
Intermittent daudication (l() is a condition caused by lack of
sufficient blood flow to skeletal muscles in the lower limbs.
Ischemia of skeletal muscles auses severe pain on walking,
particularly in the calf muscles. Although some of the ther~pies for myoc~rdi~1 ischemi~ are benefici~l in tre:oting I e,
two drugs are approved only forthis disorder. Pentoxifylline
(Trental ) acts on RBO; to reduce their viscosity and increase
thei r flexibility, thus allowing them to enter vessels that are
partiallyocduded and reduce hypoxia and pain in the muscle. Pentoxifylline also has antiplatelet action. Cilostawl
(Pletal ) inhibits platelet aggregation and promotes vasodilation, which brings additional blood to ischemic muscles.
Both drugs are given orally and show only modest improvement in IC symptoms. Exercise and therapeutic lifestyle
changes are necessary for maximum benefit.
I Clopldogrel (Plav/x)
with a f"e(t m hillory of MI, CVA, or pfflph~r~l ant rydimll'.lt is ,Iso approYed
for thrombi prophyluis in patitnts with unll,bIe angirw, induding thOll' who
a~ f"e(eiYing mrul,r bypass pnx~rures or 'ngioplasry.lt m<ly he gi!'n offl,btl to p~t thrombi formation in pillienll with (oronary <I n~ry IIt nts, <I nd
10 pre't't'nt postoptrativ~ dt~p !'in Ihromboll'S.8euUll' I~ drug is rlptnsiY~,
it is usu,lI~ pl"rl(ribf<i for pillients unable 10 toler.lte Hpirin, which h" similar
anticoagulant "tivity.lt is gWtn orally.
C\opidog~1 prolongs bleeding timt by inhibiting plolelet ,gg~9ition direaly inhibiting ADP binding to its f"e(eptor. This binding is illl"'rlible ,nd I~
platelet will he ,lfenfd for the ~l!Iiindtr ofits life sp,n.
ADMINISTRATION ALERTS
T,blen should not he {Mh~d or split.
Discomin~ drug" Ie"t Sdays prior 10 surgtry.
PrtgnallQ GIItgOry 8
PHARMACOKINETICS (PO)
Onset: 1- 2 h
!flU h
Halflife:8 h
Durat ion: Unknown
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ADVERSE EFFECTS
C\opidogr~ is gmmlly welllole"ted. F~u~nt ao:i!'lll' elfem indudt flulikt
syndroltK', headach~, diuines, and rHh or pruritus. lib> other {oaguLllion
modifiers, bleeding is a pol~mial adYffiee!'l1l
Contraindications: C\opidog~1 is (onmindicatfd in p,tieot; with <Ictm
ble~ding.
INTERACTIONS
[)ug- [)ug: LMwith arIir:~B,othfr 'n~"'lqnB, thrombol)1ic: ~
(f NSAIlS, i1ducing i!piin, wi ilKfNl,f tIN> rilk of bIKoIing. B.vbino:rs, rifompin.
(f carbarnauPllfmay
m- tlN>aoti<:NQWriatMlyof ~ 1M uoIt
0\0p1IIf 'U
]81
intefauioM.
Obtain bilfliM Might, lUI signs, ECG (if approprior~j, DI bll'olth sooods.
"'iel for plI'Wn{e, lJloIity, Ioution of.ngina, and fOf pmfII{t of ~a
or{1Ies1 ~Alsell exlttemities for IYmpIOmI of Ihrombophltb~is (t.g.,
wirmth, swrliing.l~nclrmel in (al( positM /loman's ~n) and for Iocmon
arJd dlirmnh mounl 01"'1, if pll'WnL
halua~ .ppop rMlt whomory findings (e.g., bltfding limd, (Be .nd
pLJitIeti, II'IliI I nd lim function sludift, Ind lipid profilrs..
b t ll nttnt thlO.ghout iI~nllttltion:
ASies for dnftd IhtflpMK &b (~.g., no symp!!lm! of thrombM
fonnalian).
CoI\tinut periodic ntonitoring of ilPPfOPri,l~ lib v.kIts (t4-, (Be, plill'leH,
bleeding tirMj.
A1sessbr~~OOlingfrornIlptltWDUndlirn.~mosii,~,
e,ilulis,bitfdng from gums, ind for oo:wit ~i~ sudlill pallo~dWiness,
frrpc:ttnsion, !iJCh)'!'lrdia,abcbminal pain,_111 d abdomirwl wal swrIingOf
firmlltlS,Unbir pain,Of clrmlltd ~d lDnI(ioo\ntss..
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M.,imizing.dWl'lt tffem:
Monitor 101 signs and symptoms ofbftdirg: oozing allY ~lf5 orwounck,
tcd1ymosis, peted1~, herMurw, lMc:~rry stools, rffiil blmling."wffttground ftIlf~, tpinuis, ~n9 from gums,. prolongtd lind/or ht.wy
menstNoli flow, ~nd fOf occult blctd~SU(h is pillo~ diuinesl,
hypot~ion, tach)'Cilrdi.l, abdominal pii", a~H of abdomilllli wlIll sWI!lIing
Of firmllffi, "'mbar plIin, Of deutllsed kvtI of (OIIKiousne5s, (The risk of
bWding nom IIntipialflet thtrllpy is not as ~\Iett u it is for i1111it:CWguI.UItS.
but it lllouid be monitored while tilt paticflt is on .ntip!attlet thmpy.)
Inslruct the patieftl on th~ ned til I!tum Pfriodiuily for lahorkand to
aim lab personnel tllit antiplatelet thtrapy i5 bting 1Md.
InltnKtthtpatiefttto w!)'a wallet mtmcatioftc..udOfwtar Illfdiul
idtntilOtioo jtwt try indiuting antipl.i tflt!: th~r.lpy.
Ttarn tilt patiffit, family, or uregie- to I!por1 oliff sudden pain in dlfU,
Itqs, or (.~;~ta;or new-olllet anginal pain immtdiattly.
(iostly ffiluate iIIl new pmaiptions or list of Of( mtdicatiom 10, drug
interactions. (Many drugs intelitt witlr antipla teltts. ill(ltuing the <hall( t
for ~ing. AII ore mtdkatiolll containirlg uJicy\ate!"e.g..l5pirin,and
NSAlDs.e.g.. ibuprokn, should not bt taktn unlts!othtrwist ordertd b,. a
InltnKt the patieftt to (l)fllUlt the health <alt plll'o'idef belon!' taking any
ntW pn!'S(ription or OlC Illfdiution, inWding Mrbal ~atioM.
Makhu~p!OYidK)
a~l5.)
Evaluaff thteffmMntII oIdM) tlltnpy by coofirming that ~t goal! and exptcttd outcomes 11m bttn mH (Sft!"Planning1.
Stf TIII!It ]7.4fDta I;.r tIdlugJ fD w/rIdr thtst IIInhIg IIl/iIm
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m.
Chopltl 21
383
Adverse Effects
SuptrfidDlbludflgl1lirtecrionsire\ Q//ergkrHcWIIl
\U~tokiMll' (KabikiMll')
tenenepla~ (lNK.a~)
hyptntfl~on
THROMBOLYTICS
It is often mistakenly believed that the purpose of anticoa gulants such as heparin or warfarin (Coumadin) is to digest
and remove pre-existing dots, but this is not the case. A totally different class of drugs, the thrombolytics, is needed for
this purpose. The thrombolytics are listed in Table 27.S.
27.7 Pharmacotherapy
with Thrombolytics
Thrombolytics promote fibrinolysis, or dot destruction, by
converting plasminogen to plasmin. The enzyme plasmin
digests fibrin a nd breaks down fibrinogen, prothrombin,
I Alteplase (Actrvase)
ADVERSE EFFECTS
The mOil (ommon adver~ effrCl of ik~pb se is bleeding, whic:h rTIiIY ouu, supertKiilly at rftdle pun(1uft' ,itl'S or interTlillly.lntrmaniil blffiling is i r.ne,
though poIsibit, m rw rifm Sign! of blffiling I!Kh as spomaotOlJl K(hyOIOIe, ~mitomolS, or t pistu is !hoold immediately bt I"I'ponrd to tilt htalth
m r prwidtr.
Conlraindi (ations: Al~ is (ootraindKit~d in actil' internal bleeding,history of CVA within the past 2 month n!(~m traurTlil or surgery, !f"I'1"I' unc:ootrollrd hypertension, imramnial neoplasm,or arterio'l~OOUI rTIiIlforrTliltion.
INTERACTIONS
Drug-Drug: (roru~t UII' with iIl~OIIlJwnts, iIltiplatPlft . .ts,OI HSAlIlI,
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IftfPf III M}MJrllng/l1f fer Q Mmi"9 I'rIKm F/KJJ5 J{lt(1k III rills drug.
38 4
Asse ssm e nt
forCVA.
Pl anning: Patie nt Goal s a nd Expec ted Outco me s
The~iemwill:
EllperirlKe theraprutir: ~ dl'ptndent on the ft'iIIOII the drug i, bring gil'tll (e.C)., Il'perflrsion oI(oronary anerits).
8e 1m from, olexpeOen(e minimal,.rIYers.~.
Verbalize an understanding 01 the drug's uS!', ad'/erse tffrru, and requill'd preautions.
~mon,mte prop~r stll-administration olllKffi'ry po'Hhrombolytic ml'diutions (e.g.,doIf, timing. whm to notif)o plOllidfl").
Impl e mentati o n
Interve nti o ns a nd (Rati o na les)
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theilllKffift)o priol to
beginning thrombolytic therap)'.
To allay anxiety, teoKh the ~im~ lami~, or (ale9i!'1 the lationale for all
equipmmt uSl'd.
Enroulolgt' the patient tompt , he.khy I~etylr ollow-Iatlood (hoice,
ilKlI'aSl'd eIItK~,decll"SI'd ufleinr and akohol (olllUmption,oInd
1I110king (e~tion. PIOYide fo, iI ppropriat. (onsultation (~.g., dietitian) aI
~
...
Chopltl 27
385
Monitorviul signl and ECG rl'l'ry 1Sminutes duriog the fim hour of
infulion,and !hen ffl!Y 10 milllMl dJriog ft'IIIiinderofinfusion and lor
lilt firsl 8 hours. Report ~II)' dy! rhythmias immrdilt~ly. (Obu iniog vi,,)
sigrn frequently will ilSffi for adl'~ ~ffrm of the drug indudiog
hypoltn<ion ~nd u<hyurdia asso<iarod with blHding and lor
d)'lrhythmias. Dysrhythm i.I s may occur poItperMion of the (orona I)'
arlene or may beaslOCi.lted with adYenr tffNu.)
Maintain the patitm on bedrel and with limited ictiVity during Ihr
infulion.(Limited ph)'liul mivil)' and bedrest ~aS!' thechan(e for
bruiling, iojury, a nd bleediog.)
Mooitor neu,oIo gic: SUM fft'qUemly, especially if th rombolytiG are !Md for
CVA. (A 9Jddeo diange in neurologic: staM 0' sudden I!"',r headache ila
poIIible lign of an intracraoial bietod with inm,srd imrmanill pRssure.)
To alLly poI~ble anxiety, team the patitnl the rationile for the frequent
asl!'l!O\tnu aod pKlYidt ft'assuraoc:r.
Instruct the family or uft'gim 10 report all)' change in the patitni's memill
lIatus or 1M! of ronsciousoru drJing the postinfusion period immediately.
Tu(h the patient that ~fttr aoy required procedure~ pft'lSU~ will be
maintained to the sit~ for a prolonged period oltime.
Continue to monitor lab work (Hgb, Hct, pla!~lel (ounu,and bftdiog rime)
freqUtnlly POSH~~tllll'lli.PModK CBe aod ABGI may also be monitored.
Activity may be limited duriog thil poltiofusioo time period. (The risk of
bleeding remainl high for 1 to 4 day; postinfusioo.)
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386
TABlE27.6
H@mostatics
Drug
Q
Adverse Effects
nep/nIOlicilV
'llinocaproic:~ (Amic.u)
'prolinin (Tlu)'IoI)
trinwmK add ((ykIobpron,L)'\l~)
HEMOSTATICS
Hemostatics, also called antijibrinoiytics, have an action opposite that of anticoagulants: They shorten bleeding time.
The class name hemoswtics comes from the drugs' ability to
slow blood flow. They are used to prevent excessive bleeding
following surgical procedures.
27.8 Pharmacotherapy
with Hemostatics
The final class of coagulation modifiers, the hemostatics, is a
small gro u p of drugs used to prevent and treat excessive bleeding from surgical sites. In addition, an oral form of trane:GImic
acid (Lysteda) was approved in 2009 for the treatment of heavy
menstrual bleeding. All the hemostatics have very specific indications for use, and none are commonly prescribed. AI
though their mechanisms differ, all drugs in this class prevent
fibrin from dissolving, thus enhancing the stability of the dot.
The hemostatics are listed in Table 27.6.
ADVERSE EFFECTS
Btcalllf aminouproic ,rid trods to stabilize (1011, it should ~ us~d uutiowJy
in p,titnn with a history of thrombofmbolic dilf.J ~. Rapid IV ,dminisuuion
may uu~ hypotension and/or br~dyurdia. Side tifls uegenmlly mild.
Contraindications: Aminouproic acid is (onmindicattd in pititnll with dislfIIlin,ttd imliv.tI(IJiar(lotting or \e'IM' It'nal impairment
INTERACTIONS
I)ug-l)ug: fiyper<Nglllition may 0\1 with IOOInffllllll' of estrogi'rlI and oral
<DIlriKfII1i'll"l.
PHARMACOKINETICS (POI
()(lft: Unknown
PNk:lh
Half~i~:Unknown
D.!ration: Unknown
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387
illlrnva,~ular
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388
Unlt4
1. A patient is receiving enouparin subcutaneously after beIng diagnosed with thrombophlebitis.. What precautions
should be taken when giving this medication?
See Appendix D for anSWf71 and rationales for all activities.
r--i~"------,
EXPLORE ~
MyttJrsirlgt<i! is
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DRUGS AT A GLANCE
(XTJt J\tl
PlateletEnhancers pu;elW
ANTIANEMIAAGENTS f1JI}tJ98
""
{IJge 398
KEY TERMS
anemiil fX1I}tJ9l
(olony-stimulating factor(CSF)
erythropoietin {JQIIt 191
ferritin (X1IJt399
PU;f 394
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folicacidffolate (X1IJt399
heITliltopoiesis fIO'It m
hemosidrrin Jl1Jt 399
intrinsicflctor paJtJ98
pemicious(mr galoblastic)lnrmia
stem (fn {IOtItNJ
thrombopoietin (JO"/t 397
transferrin fIO'It 399
(X1IJtm
390
Sy""'"'
he blood serves all other cells in the body and Is the only
ma,,,,w
will affect cells in many different tissues. This chapter will examine medications used to enhance the functions of erythrocytes, leukocytes, and platelets. Pharmacology of the
hematopoietic system is a small, though emerging, branch of
medicine.
28.1 Hematopoiesis
Blood is a higWy dynamic tissue; more than 200 billion new
blood cells areformed every day. The process of blood cell for
mation is called hematopoirsir, or hemopoiesis. Hematopoiesis
occurs primarily in red bone marrow and requires B vitamins,
vitamin C,copper, iron, and other nutrients.
Hematopoiesis is responsive to the demands of the body.
For example, the production of white blood cells can in
crease to 10 times normal in response to infection. The
nwnber of red blood cells can increase as much as 5 times
normal in response to blood loss or hypoxia. Homeostatic
control of hematopoiesis is influenced bya number of hormones and growth factors, which allow for points of pharo
macologic intervention. The process of hematopoiesis is
illustrated in .. Figure 28.1.
Hematopoiesis begins with a sum {ell, which is capable of
maturing into lInytypeofblood cell. The specific path taken
by the stem cell, whether it becomes an erythrocyte, leuko
cyte, or platelet, depends on the internal needs of the body.
These needs are transmitted to the stem cells bywayof hor
mones and other regulatory substances. These control sub
stances include erythropoietin and chemicals secreted by
leukocytes known as colony-stimulating factors. Through
recombinant DNA tt'l:hnology, some of these regulatory
agents are now .available in sufficient quantities to be used as
medicatioIl'i.
PHARMFACTS
Hematopoietic Disorders
Apmjnant woman', body procb:~s 45% mo~ blood b.iUIl' it {ontains
nlllritnuand oxygtn for t~growing fetus.TIIt g~at6t ill{~u~ in blood
procb:tion O{{u~ around Wffk 20 of prl'gnanq.
Adtficitnc:y ofvitamin H",folat~or vitamin S. may in{lt'~ tht blood
~ ofoomocyst~illl',an amino acid normall~ found in th~ blood.An
elevattd blood IrwI of OOlllOC"fSteilH.' ~ a risk factor for hun dMill' and
,"".
VtgI'tanans who do not rat IIII'm,mh, ~ggs,m il~ or milk products arl' . t
high risk fordewloping vitamin H" defKifru~. Vtgmrians may find
adtqwtt amounts in fortifuod (moals, rutritional suppltllll'nts,or ~mt.
Admin~tr.nion of folic acid during Jlrl'9nancy Iw ~n found to It'(]UCf
n!'Ural tube birth dmas in t~ newborn.
HeolV)' mtnstrual ptriock mayIt'IUk in ronsiderablt iron loss.
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Megakaryoblast
I
Th"'mbopoielin
tlllorieo.A<intt
Leukocyte
atom ""U
Colonystimutating
~cto ..
~,6f
0".......
Platelets
Erythrocyte
stem ""U
Macrophagos
.. Flgure28.J Hematopolests
"a ..
c
G,atl~ocytes
.-'.--.
Erythrocytes
__" ,",",. , 1.
'"'......"V...5.""'~'P.W.
I" .
391
Adverse Effects
"'f..........""'_.. ~"'_
COLONY-STIMULATING FACTORS
Go) rdgraslin !HtuplHJftl):
gr.IIJIocytKSF
ptqfilgmtim (He~\lal
!anJ~rnollim (llutilN'j:
dlfmOlheiaP'l'
gr'lIJkqt~moKrophoogK5F
PLATELET ENHANCERS
oprrl'lrlin (NfIIIIIf9i)
.nal!!!rl";~!In!!!l1hm;~
fllrombopag (f'romau.)
rompJoltim (HpI.le)
m(9lbj/Wk)
m.~glliw.~lolOJ:id!! {fltrornboo')(]i
28.2 Pharmacotherapy
with Erythropoietin
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392
ADVERSE EFFECTS
The suocutall!OUS nxlte is gtoerally pn!'ferred o~r IV, since IooMr d~ all'
I"ftded .nd a~tion is slower.
Do oot shake the via l beca!M this may dtacti'late tilt dlll9. Yrsibly insptd
the IOkrlion for paniculate matter.
Plf9nancy cattgory (
PHARMACOKLNETICS (SUBCUTANEOUS)
()JSft 7- 14days
~ak: Unkno\\ll
Hall~ir.: 41l h
Duration: Unknown
Epoetin alia haslnl'ral FDA bond warnings that indudt tilt fol'a.ving:
The dlll9 may inclNse the risk of II'rious wdiomrulu nffits, thromboembolic ~nu, and mortality.
The dlll9 may shorten survival time and promoll'tumor progression in p.tifots with certain cancers sud! as bn!'ast, cervical,. nd lung CI nm.
The druq may incll"lI' mortality and II'rious urdiomrula, tl'fOts in patMoots with chronic II'nal laikrn!'.
The dlll9 may incll'.!II' the risk for deep vein thrombcr;is (DVT) in
perisurgel)' patients not rtleMn9 antic:o'lJllant prophylaus.
H)'p!'nemion may occur in as many as 10% of patients II'criving the drug,
.Jnd a conrulft'nt .ntih)'p!'nensive dlll9 may ~ indicattd. Other ~nt adve~ efFects include htacbcht, fem, nausN,dianllt., and edtllY.
Patifnts taking epoetin .J Ifa who all' on dialym nwy n!'q uire ilClI" ltd doses
of heparin to m.Jintain adf<JUiIf anticoagulation. Transitm ischemic att.cks
(nAs), hun attacks, and strokes 11m occurred in chronic II'nal lailure paritnll
on dialysis being trmed with epot1in all.
The efFectiveness ofepot1in alf~ will be 9,e<ll1y rtducrd in pa1itnts with iron
dtrKMoncy or other vitamin-dtplettd statH. Most p.tMontSll'Cti"l' iron supplements during therap)' to compensate fo, tilt incn!'.!II'd rro blood rell produnion.
Contraindications: Contraindications indudt uncontrolled h)'pfrtl'llsion, and
known hypersmsitivity 10 m.Jmmalian [ell produru.(all' must I;e taken not to
.Jdminister ~tin Ha 10 paritnts with myeloid nwlignancMoslIJ(h as lIl)'eiogtnousleuktmia beca!M the dlll9 nwy incll"~ tumor growth.
INTERACTIONS
I)ug- l)ug: 1'-aft' oodnic;;)ly~tO:lHj irI~Jacticn!; with ~ ilia.
labTests: lktnown
IIorbovr 00:1: Unknown
T~tment of Dmdosr: Ol'ffiloll' may lead 10 po~tmia (too nwll)' f rythrocytes), which can ~ COlll'<1ed by phlebotomy.
Assessme nt
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393
Assessm e nt
Advise the patiem to (onsult with the health (1ft' provider about
driving orother hillan:lousactivitil"l duringthe first It"VfIiIl momhs of
drug therap)'.
To allay anxiet): offer part'nt> rationales for all tre~trnenu provided lor
the infant
ruion~le.
rContlrnJedj
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394
Ih~
patient should lItabk to state th~ INIon for the drug. . ppropri.J1l'
to 00rr1ft for and whrn to
report;.nd the anticipaled length of medicalion thffilpy.
dilurded.
II indWl'lIing subanantOlll 10ft mlltt~r (e .g.,llIIUfIon soft !athrler), the
p.lIien~ family, or Llll'giver should lit taught a pproprull' site m~. inrrrtion
te<hniqut as appropriat~, or !{hl'dult for rotolling sites.
leukopoiesis, is more complicated than t'ryIhropoiesis becaust' there are difft'rent types of leukocytes in tht' blood.
Pharmacologically, the most important substances control~
ling production are {olooy-st imulating factors ICSFsI. Also called
leukopoit'tic growth factors, the CSFs comprise a small
group of drugs that stimulate the growth and differentiation
of ont' or more types of leukocytes. Doses for these mt'dications are listed in Tablt' 2B.I.
When the body receives a bacterial challt'nge, the production of CSFs incrt'3ses rapidly. The CSFs are active at very
low concentrations; each stt'm Ct'll stimulated by these
growth factors is capable of producing as many as 1,000 mature leukocytes. The CSFs not only increase tht' production
of new leukocytes, they also activate existing white blood
cells. Examples of enhanced functions include increased migration of leukocytes to the bacteria, increased antibody
toxicity, and increased phagocytosis.
CSFs are named according to tht' types of blood cells that
ther stimulate. For example, granulocyte colony-stimulating
factor (C-CSF) increases the production of neutrophils, tht'
most common type of granulocyte. Granulocytelmacrophagt'
colony-stimulating factor (GM-CSF ) stimulates both neutrophil and macrophage production. The process of identifying the many endogenous CSFs, detennining their normal
functions, and discovering their potential value as tht'rapeutic
agents is an emt'rging area of phannacolo gy.
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Tht'goal ofCSF pharmaotherapy is to produce a !"lipid increase in the number of neutrophils in patients who have
suppressed immunt' systems. CSF therapy shortens the
length of time patients are susceptible to life-threatening in fections due to low numbers of neutrophils (nt'utropt'nia).
Indications include patients undt'rgoing chemotherapy or
receiving bone marrow or stem cell transplants, or who have
certain malignancies. By raising neutrophil counts, CS Fs
can assist in keeping antineoplastic dosing regimens on
schedule (and more rlfective) .
Fil grastim (Neupogen) is similar to natural G-CSF and
is primarily used for chronic neutropenia or neutropenia
secondary to chemotherapy. Pegfilgrastim ( Neulasta ) is a
form of filgrastim bonded to a molecule of polyt'lhylene
glycol ( PEG). The PEG decreases the renal excretion of
the molecult', allowing it to rt'main in tht' body with a sustained duration of action. Sargramostim (Leukine) is
similar to natural GM-CSF and is used to treat nt'utropt'nia in patients treated for acute myelogt'nous leukemia,
and patients who are having autologous bone marrow
transplantation.
28.4 Pharmacotherapy
with Platelet Enhancers
The production of platelets, or tltromboqtopoiesis, begins
when mt'gakaryocytes in tht' bone marrow start shedding
membrane -bound packt'ls. These packt'ts enter the bloodstream and be.:ome platt'lets. A single megakaryocyte can
produce thousands of platelets.
39S
ADVERSE EFFEaS
Although filgr;mim is wtli toltrattd, tbt dl1J9 is associlttd with potCllti.J11y Ifrious idwr..e fffKtS ind clost monitoring is ~uirm80nt piin miY o(aJr in up
to 1J9Io of pat1ttllS If(tjying tilgliIstim.Asmall ptltl!fltagt of pititMS may !It~p an allelqic ~action. FrtqUl!flllaboratory Itlts al1' 1Il'Ss.ary 10ellWI1' that
fX<tSsivf IlUmbtrs of nMlllphib, or leukocytosis, dots not O((\Ir. leubxyte
(000\5 hi9her rNn 100,000 mls/mml ilKrwt lhe risk of Ifrious .dlfml! riftru wch is I1'Spimory failul1', intracranial hemonflagt,l1"Iinal hemorrhage,
<lnd MI. F~aI rupturt of the ~ !ws OIJrrtd in a lIIIall ,...mbtr of pititnts..
Contraindiations: Tht only (ontraindiGItiOll is hyptflfnsitiYity to f. aJli pili
INn ~ "'is mKrobt is II!td to ,MIKe thf If(ombillilnl drug.
~lYinfusion.
ADMINISTRATION ALERTS
Prtgnancyutl!gory(
PHARMACOKINETICS ISUBCUTANEOUSI
Onstt.:. h
P9:2- 8h
Half-lilt:lS h
lNTERAalONS
Drug-Drug; 8fCiUse ilIl!illtOP6ti: dllI9S and ~-Rilll.Hing b<t0l5 prodIKf
oppoIitf rJrKl5,rqaitim is IIOIDninistfflld unl~ iIIltJast 241Hu51fifr a
ct.erIIOIhtf~ !tIlion.
*'
DlI'ation: 1wk
AsseS5ment
Baseline tlSH5Imtnt priorto 6dminhtriltion:
Undtnlind IIIf ~ the d~ has betn prNribtd in order to iS~S for
IflfrlpMic riFects It.g., neu\lIIptnia. h!ukopmia, se<ondary to(ifl(tf
UNtmtnt, HIV, post- bone marrow transplanlL
Obuin i complete heilth history irKb:ling rt'(~nt or Clllltllt infections, '~WII
wrgI! rit1, injuries or 'Mllinds, )'9st infections It.g., tlwsh), vHcinitioo histOf)",
c.udiac conditions If.g.,dyrhytllmias, (HF), or I1'spirKOf)", I1'IIoIl,uld htpatic
concf~iofls.Obliiin <I drug hislory including .llellJits. cu~nt pMplion <lnd
Ol( drugs. hefbal Pftpilillions,.ndakoilolust.Be.lerttopossibledl1J9
inltQ(lions.
Obtain iwltlinf "Wti9ht Md vi(.Jl5igns.AsstSllevtl offatilJ.lf.
Evaluab! appropnm wbOfatory findings (e.g.,(BC, WBC 01 absolutt neutrophil
count [ANell, JMlI.nd liver function nudil'S, uric acid 1fflk,;tAd Wi.
[ANe = TOIiI WBe counl multiplied II, 1M IOtai ptf{emq of nMrOpililis
(segs pUs b.inds);e.g.,WBC 5000 X 10.45segmentedneutlllphih + 0.05
~ndtdMt.llJOphiis) = SOOO X 05 = AH(oflSOO.]
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] 96
TM~iffitwill:
ExpentlKt ther~pMK tfftru dtprndent on the It'aIOII the drug is being giYeO (t.g.,oprntncr inumt WBUAN( Irvr~ no signs or s)'Illptoms ofinfKtion).
St fire irom,or experiencr minimal,,,I"lerst rifKlS.
VMlalino an understanding 01 the drug's u:;t, oJd'Ierse tfftru, and Il'qJil1'd Pll'Uutions.
DtlMllstralt prop~r selhdministr~tion of the rnMiution (f .g.,do!t, timing. when to nooft pfOl'idtr).
Implementlltion
Inte rve nti o ns li nd (Rllti o na le s)
';
;ft ';ff,.I"ft~WOr
.. "'"""fWW,;"
~"" ,. ...
~3
' _"
..
_ .......
... .. y, ~. ~ .~
,y ""'."~~
..
.. y . . . u-. .......
u ...
... .u.
~~ ,
y~
".y~~".y
Mainlilin m. tirulous inil'ction control measul!"!. Rtpon any !oigns and symptoms
01 inil'ctions ormer imrnMiattly. (TM piltient will cominue to be,t risk for
infKtions umil WBClANC 1!o~1s rist. OpportunistK inil'ctions sum as ~tast and
virum SIKh as herprs ~mpl!ox maY lXcut Pilramrtt~ will be!d by heil hh ('It'
proYicler for Il'pOning ftl'e<. e.g.. all)' ttmjlfraNIt' Ultl l005'F,dtptnd..,t on tht
underlying dill'<I:;tcond"rtion and dfllCj ther<lPY.)
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397
Stop iidminimation whtn WBC (ounts IN<h t~ IeYeI determi~ byt~ h~,1th
plO'lider.(FiIg,aniIlIllilY ~ nopped ....t.en neutrophil loom, ft'ath
lO,OOO/mm'; wrg ...nonim II\a)' ~ SIOp~d w~n n~l/Irophil (ounts ft'alh
20,OOO/mm' 0' u ordeF.d by the ~.kh laft' provider.)
(ii'"
T~ath t~ patient.bout t~
~.
~ft'.,.)
dist.ardtd.
II indwt-lling lUocutntou, soft W~te1 (t .g. Insuflon soft mheter) is!Md.
tht patient should ~tau9ht ' ppropri,te sit~ ure, inlfllion \l!(hn~ u
'ppropriate,or I(iledule for rotating sites.
Evaluation of Outcome Criterill
Evaluat~ the ~ffeui'lelltssol drug
tht"py by (onfirming that ~titnt IjOiIs~nd"~ OlI(omrs hal'!' bfen mtI ( ~ Pt.nning1 .
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ANEMIAS
Ant mia is a oondition in which red blood cells have a diminished capacity to deliver oxygen to tissues. Although there
are many different causes of anemia, they fall into one of the
follmving categories:
- Erythrocyte lo.ss due to hemorrhage
_ Increased erythrocyte destruction
_ Impaired erythrocyte production
398
TABLE 28.2
Classification of An"mia
Morphology
Description
Examples
MamKytiI: - 1IOIIIIIXI'Iomic:
Mi(f()()1k- h)'pXhromi(
Nonnocytic:- oormodlromic
A~ic illl'mi"htmoohigi('lII'mi"Ii!kl~
CflI.ntmia, htmoIytic:.ntmia
"
!
TABLE28.3
I"'. ,
ANTIANEMIC AGENTS
Depending on the type of anemia, several vitamins and
minerals may be given to enhance the oxygen-carrying capacity of blood. The most common antianemic agents are
cyanocobalamin (CaloMist, Nascobal), folic acid (Folvite,
olher,), and ferIOw; 5ulfale (Feo"",l, 0Ih"r5). TheM: agent.
are listed in Table 28.3.
28.6 Pharmacotherapy
with Vitamin 8 12 and Folic Acid
Vitamin B" is an er.senlial component of two coenzymes that
are required for actively growing and dividing cells.
Vitamin Bll is not synthesized by either plants or animals;
only bacteria can make this substance. Be.:ause only minuscule amounts of vitamin B" are required (3 meg/day), deficiency of this vitamin is usually not due to insufficient dietary
intake. Instead, the most common cause of viI amin B" deficiency is absence of intrinsi: factor, a protein secreted by stomach
cells. Intriru;ic factor is required fur villlmin Bll to be absorbed from the intestine. Figure 28.2 illustrates the metabolism of villlmin B". Inflammatory diseases of the stomach
or surgical removal of the stomach may result in deficiency of
intrinsic factor. Inflammatory diseases of the smaU intestine
Antianemic Agents
urug
IOO-200rtKg/mo
folbdd (FoIvitd
IRON SALTS
Adverse Effects
I-'~-'"
No~elftm
~rlOlJllUlfate l~,othen)
~lIIIIIlIytoI(Fmhf,RII'l
""""
ftrlOlJl fuma,att
(Fro!ta~othtrs)
~rlOlJl9kKonate (~rgon)
lt08da~l.ntf
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IF"
Inln15i~
factor
Th e QUfstion: Doe folic: add rmuu the inddl'nc:1' of ~ral rubt rll'fKts if
takrn prior to pregnancy? It has ~n ~ublishtd for s~rill rlrurll's that
folic: idd rll'fic:iI'n{1 ruring p~nil nq iOOl'iI~ th!o risk of Ill'Ural tuilt
rll'lKts in the IN'wOOrn,and that ~I'jyjng adrqua1l' amounu ruring
p~nilnq {.In rtduc:t th!o rill Ho-.e~doH folic: id e~n th~
protliYt> rffl if taken prior to pregnancy?
Th e Stull,: TIll' authors ~ studies perfonntd siIKe 1996. Rl'learth
supporttd the (ondusion thilt folic: illid supplrmtnution ruring the
perKontl'ptional period did inrll'ed redUtr the risk of neural rubt rll'fKts.
Furthermort, supplementation with 0.4 mIg WilS not ilS!01Wtd with any
ilcivtlll'l'ifKts.
Nursin g lrnplitations: Hal/of all IRgnanc:ies illI' unplanntd.Thus, tht nurn
should ~ommrnd folic ildd supplemr mation for all womenwith a
lI'aIOnablr poIsibilil)' of pll'gnancy.
5aru: Wt>lI" l, irtiloKlrltJ> K. Allltl M.&5)f 5 (lOO9). (of{ k1fI
~rilfrr"'rMPrmMk1ItrlNt!lalllbf fJt/t(/',:Ai1 !IpOOII>I1fllrtErldtm
fwllrtll.i PrMIrlIw 5tntt! ill.tflm. Anrlilll OI'lnternat IMdIdtli 15IJ:6J1--6J9.
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In fact, the metabolism of vitamin B" and folic acid are intricately linked; a B" deficiency will create a lack of acti
vated folic acid.
Folic acid does not require intrinsic factor for intestinal
absorption, and the most common cause offolate deficiency
is insufficient dietary intake. This is often observed in patients with chronic alcoholism because their diets are often
deficient in this nutrient, and alcohol interferes with folate
metabolism in the liver. Fad diets and malabsorption disorders of the small intestine can also result in folate anemia.
Hematopoietic signs of folate deficiency are the same as
those for B" deficiency; however, no neurologic sigfl'i are
present. Folate deficiency during pregnancy has been linked
to neural birth defects such as spina bifida.
Treatment of mild deficiency or prophylaxis of folate deficiency is accomplished by increasing the dietary intake of
folic acid by including fresh green vegetables,dried beafl'i,and
wheat products. In cases when adequate dietary intake catulot
be achieved, therapy with folate sodiwn (Folvite) or folic acid
is warranted. Folic acid is discussed further in chapter 4200,
where it is a drug prototype for water-soluble vitamins.
400
UnII4
Th<>(~ ,d""'.",ul.,.nd
U'I.... ry
Syne<",
I Cyanocobalamin (Ca/omlst,Nascobal)
PHARMACOKINETICS
Onset: D.ys toWffks
Peak:8- 12 h (P01,1 - 2 h (intr.n.san,ind I h (IV)
Halflife:6day\
Duration: Unknown
INTERACTIONS
I)ug-l)ug: Drug il1noKtionl with cyanocobalamin indudt ~ dtouNII'" .bsoIptioo
iron requirements in most individuals quite smaU. Iron bal ance is maintained by the increased absorption of the min
era! from the proxitllill small intestine during periods of
deficiency. Because iron is fOWld in greater quantities in meat
products, vegetariall'i are at higher risk of iron-deficiency
anemia.
Iron deficiency is the most common cause of anemia. More
than 50% of patients diagnosed with iron deficiency anemia
have GI bleeding, such as may occur from GI malignancies or
chronic peptic ulcer disease. In the United States and Canada,
iron deficiency most commonly occurs in women of childbearing age due to blood losses during menses and pregnancy.
These conditions may require more than the recommended
daily aUowance ( RDA) of iron (chapter 42(0). The most significant effect of iron deficiency is a reduction in erythro
poiesis, resulting in symptoms of anemia.
Mild iron.defici.>ncy anemia may be preVi'nted or cor_
reeted by increasing the intake of iron-rich foods, such as fish,
red meat, fortified cereal, and whole-grain bre;lds. For more
sewre deficiencies, ferrous sulfate (Feosol, others), ferrous
gIuoonate (Fergon), and rerrous fiunarate (Feostat, others)
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ADVERSE EFFECTS
Adft~tflectl from 'Y~nocob~lamin a~ ulKommon.Hypokalemia is possitk;
thus. I!'IUm potas~um Itl'tk'f"! monitorecl periodic.lly. Asmall ~rcenta9t of
p~titml rt<eiving Bu ahibit ralhts, itching, ar amf r \igns of ~Iltrgy. Anaphylaxis is poISiblt,though ral!.
Contraindicatians: Comraindicatiom indudt \emitivity 10 cobak Jnd folk
~cid-deficien'Y .nemia. CYJnocoba Ia min is rontraind iuted in patitnu with It~t~ pulmoni ry diltal!'.nd !hoold bt ulI'd C.utioUiIy in patitnts with ht.n
dM.m btuUIl' of tilt pottntial for lOdum l!1ention (iusfd by the drug.
..
Prototype Drug
Therap~tic Class:
401
Age-mfor anemia
ADVERSE EFFECTS
Thr most frrqutnt~l'ffoo oIfo=us~tr isGI upld. Taking mr,drugwith
food will dininish GI symptoms but (an <trmi\l' mr, absorpti:m of iron b)' SO% to
70%.In iddition, an!aCids should oot br taktn with frrroui sulfatr brcao:M Ihr)o
also Itdt.Kt absorptiGn 01 tilt minml.ldtally, iron ~pal1tiMS should lit ministrrrd 1hou- brloreor 2 hounaftrr a meal.lron prepariDons maydarllrn stools,
M this isa harmlrss sidfeffra.Constipation is rommon;thrrrfo~ an ilKlNlr in
dirt.lry fibtf may br ildic.nfd. Ell:rssi~ dosrs d iron are vrry 1OlK, and patienB
sIKUd br advisrdto taq.thf mrdiation aKliy.s dirrctfd.
Contraindications: Iron salts druqs Ihould not br usrd in hfmolyti anemia
without documentation of iron derKirncy ~usr iron will not rorlr(t this rondition and it maybuild to toxic: 1eYeIs.Thr drug should not br adm inil1rffll to patienB with hrmochrornatosis, prpti ukrr, rrgional t nttritis, or ukrrativf colitis.
ADMINISTRATION ALERTS
When ad ministrring IV, ~ u rrlulto pre-Y!'nt inlikl1ltion, as iron is highly irmating totissurs.
u th. Z-Irl<k mrthod (dr.p mu.d.) whrn giving 1M.
Do not crush tablet or rmpry conttnB 01 upsukrwhen administrring.
Do not givr tablet;orcapsules within 1hour 01 bedtime.
Prrgnancy utfgory A
INTERACTIONS
Drug-Drug:.I.bsorp!ion ~ rtdlKfd "Ithfn 001 ion ...m an ~ (OIKU!Il'II~' with
MlUOOs, prOlonpump in~ibitoo, or <akium su~n. ~on drcrNII'! thf
ab>orption 0(1l'In<Jd ..... fi~inoIonH,"'" Midronar: .To pr...rl! ""'....
intflactioni, ~ i!iadvisabk> 10 00 iron ~1I1 to 1hcHn iIaoor after 0Ihtr
PHARMACOKINETICS
Bfcausr iron isa naturalsubst.lnce,it is difficuk to otcain pharmacokinrti
valurs.
I!II'dcation~
Treat mem of D"ftrdOSl!: Thr ntidoll' for acute iron intoxication is defuroxaminr(Dtslenl). This parenteralagrm binds iron, which is subsequtntly rl'mOl'd by thr kKlneys, turning Ihr urinr ~ rrddish brown color.
III'ftrlJl M)Nu~mgm""QNrJrllnl} Pn::mJ FOOIIlpf(l/{lJIfIr/s~
Assessment
Basrline nsrssmenl prior 10 admin islr. tion:
o Undentand thr INIOn thedlllQ has ~n prrscribed in order tOillfSslor
tht rapruti tflrm (t.g., t)'pr of anrrnia:lfCondiry to inft.tmmatol)' ~I
disf.N,lack oIvit~min B",rtd.
o Obtain a rompiete h. akh history induding (irdiO'/i\(\Jlar,GI, h' paric,or Jl'llil
disr.N. Obtain a drug history including illt"lies,rulTrnt prf"ICription ind OK
druqs,and hfrbal prrpal1llions.Br alen to possiblt drug imrractions.Obtain a
die\al)' history, including akohol Ulr.
o Obtain b-mlilll' wright and vit~lsigns.AslfSs fat9Je boeI.
o Evakiatr i ppropriate labomoryfindings (r.g.,(B(,rltctro~tes, transferrin and
!e!Um f.. min ~Is, rrnal and liverlunction studir1.)
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Tt~
the ~tirftl to in~se ~akr of folic Kid,. vitamin B" ~nd irm
Mini.,izing 1m rw effKts:
d"",
~.H vitarnim.nd Iron prtp.ntims out oftht reW! ol)'Jung childrfn. (Iron
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1Wm~lopole(k
DI5ordE<s
403
28.2 Erythropoietin is a hormone that stimulates the production of red blood cells when th e bodyexperlences hemorrhage or hypoxia. Epoetin alfa is a synthetiC fonn of
erythropoietin used to treat specific anemillS.
2&.S Anemlasare disorders in whkh the())(ygt'Il.carrylng capacIty of the blood is reduced owing to hemorrhage , excessive erythrocyte desl:ruction, or insuffICient erythrocyte
synthesis.
21.6 DefICiencies in either vitamin 0" or folic acid can lead to
pernkious anemia. Treatment with q:an()l;obalamin can
reverse sy mptoms of pernicious anemia In many patients..
although some degree of nermuo; system damage may be
pt'"Tmanent.
NCLEX-RNOREVIEW QUESTIONS
""'-
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2. WBCorANCrounts.
J. electrolytes.
4. RBCoount.
The nursing plan of care for a patient rKeiving mgrastim
( Neupogen) should include:
l. frequent observ.iliollS for infeaion.
2. frequent monitoring of vital signs, especially blood
p~.
.. 0..
2. A patient Is receiv ing filgmstlm (Neupogen ). What nursing intervtntions are approp riate to safely administer this
dmg and provide patient safety throughout therapy!
EXPLORE
rm"iI!lit1ht3!tl:r------,
MytlIl'Jingll.ills
you r one
SlOp !of
onl.ne tl'lljltet'
~ew
mmnli!r and
resoorces..
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Chapter 29
Drugs for Shock
DRUGS AT A GLANCE
LEARNING OUTCOMES
O ~tI'f'hr1nf!(I.MlphfodJ
INOTROPICAGENTS
4. Compare and cont rast the use of co ll oids and cry$tallolds In fluid
VASOCONSTRICTORSIVASOPRE5SORS
pogtO
ptJI4J J
ptl/tfIJ
AHAPNYl.AXJS , .41J
Q fPlMphrn.(Adrrno/lfl) pogtf/4
repillCement ther,p)'.
S. list the drugs used In the prn.rfTIKothe rapy of anaphyluls and discuss
IMir indiGlltiom.
KEY TERMS
crysuloids
hypoYOitI1icWKk pqo
stpticlhod pq );
<oIoiIk
inotropic~1 pl//t4ll
""'" ""''"
ptIIJtU
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poqtG
f\turo9!'nicshoa
(XIqtJiJ
406
not
may lead to irTeYenlble orgllf'l dllmllgt lind dellth.lhis chapter examinH how drugs lire used to aid In the treatment of
different types of shoo::k.
Naurologi~
R..........
AAAiOlly
eo_
. """",",
"'"
.,..
0....,
' CoO
the vital organs, with the heart and bnJin being affected
early in the progression of the disease. Assessing the p~_
tient's cardiova!iCular st3tus will provide important clues for
a diagnosis of shock. Blood pressure is usually low and cardiac output diminished. Heart rate may be nJpid with a
weak, thre:ady pulse. Bre::IIhing;$ mu~Uy rapid ~nd ' hallow.
~ Figure 29.2 (page407) illustrates the physiologic changes
that occur during circu latory shlxk.
Sbock is often classified by naming the underlying pathologic processor organ s)'!itt'lll causing the disease. Table 29.1
describes the different types of shlxk and their primary
causes.
The diagnosis of shock is meiy b3sed on nonspedfic
symptolll5.A careful medical history, however, may give the
nurse valuable dues as to wh.:!t type of shlxk may be present. Forexample,obvious traum3 or bleeding would suggest
hypowlemic:shock, related to volume depletion. [(trauma to the
brain or spinal co rd is evident, neurogenkmock, a type of distributive shock caused by a sudden I06S of nerve impulse
commWlication, may be suspected. A history of heart dis
ease would suggest mdiogenic Ihcxk, which is caused by inadequate cardiac output due to pump failure. A recent
infection may indicate septic shod:, a type of distributive
shock caused by the presence of bacteria and toxins in the
blood.Ahistoryof allergy with a sudden onset of symptoms
following food or drug intau may suggest <II\lIp/lyl~tK lhoa,.
the most severe typt' I allergic response. The phannacotherapyofanaphylaxis is included in Section 29.7 (page 413 ).
Reapi"'ory
Rapid bmalhing
ShrIUaw
respiration
Metabo.i....
Law tlKllpllra\u",
"'"'
' Acidoaia
PHARMFACT5
Shock
C.rd"""",K. " ... k, ~ it "'I""otb ...,...1, (U U~""IfIJ(,i:. ~~ "IU>(
!elh,1 ronn of shoc:k "Id h.H an ~ to 1~ moruli!, r~tt.
Hyporolrmic ihcxkarrieu 10'M01D31~mortalilY rMe.
With ,nap/lyiauic or distributlft shrxk,duth (,n ensuewithin minufn if
trrurTIent is IlOl mil,blr to trrat tllecondition: Neuroqenk shoc:k is.
form ofdistributiYr shcxk.
It is fltillYttd that SOO to 1,000 ast5 offaQI an.lphy],ctK shcxk occur
eKh)'ritl' in tht Unittd Slam.
xplic sllodr.. uswIIy CMIIfd by I}I'mfle9itlYe ",ttrii, his.l morulity
mr of 4O'Iji to 709& but an "" as high 1\ 9O'*.clepeftding on the
UUIoIlivr Of9inism.
~
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( lIo",tll'
407
Increased rani'"
Increased aldosterone
angiotensin """ration
"""mtion
Incmase<l antidiuretic
Incroasad
admnetgic
ltCtivity
r---!~------------------~--~
,.,........
Vaooconstrictora
Norepinephrine
Inotropic agenlo
Dopllmine
Crysialloide
.5".
dexlr<l....-t-!:p
Albumin
,....,. "'"
cer<liac output
Definition
Underlying Pathology
Anaphybnil:
Cardio9ffiit
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40 8
interventions of maintaining the ABCs of life supportairway, breathing, and circulation-to sustain nonnal blood
pressure. The patient is immediately cOIUlected to a cardiac
monitor, and a pulse oximeter is applied. More invasive monitoring (e.g., arterial line monitoring of blood pressure and
pulse rute) is often required and should be started as soon as
feasible. Unless contraindicated, oxygen is administered at
15 Umin via a nonrebreather mask. Neurologic status and
level of coll'iciousness are carefully monitored. Additional
nursing interventioll'i coll'iist of keeping the patient quiet and
wann and offering psychologic support and reassurance.
The remaining therapi .... for m<><:k depend on the specific
cause of the condition. The two prilllilry pharmacotherapeutic goals are to restore normal fluid volwne and composition and to maimain adequate blood pressure. For
anaphylaxis, an additional goal is to prevent or stop the hypersensitive inflammatory response.
Examples
Blood produa\
whol~ bb:>d
pIa!olna prolrin fraction
Ireh fr=n pia IIIU
Cd""'
httaslilrm{H~)
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VASOCONSTRICTORSIVASOPRESSORS
In some types of sh<><:k, the most serious medical challenge
f~"illl\ tit" l'~ti"JJt i, I'Yl'u["Il,iuIl, wl,iul 1ll~1 J.,""Ulll" so
profoWld as to cause collapse of the circulatory system.
Vasoconstrictors are drugs for maintaining blood pressure
when vasodilation has caused hypotension but fluids have
not been lost (i.e., anaphylactic shock) and when fluid replacement therapy have proved ineffective. These medicn tioll'i are listed in Table 29.3.
Cllopltll'
4 09
ADVERSE EFFECTS
BeuUlfalbumin ~ a mural blood prodlK~ the patitnt may havfimiborJies to
the dorm album in and i Ilfrgic ~actions a~ pos,ibl!-. HaMvel', coagulation lac:tors, ontibodie<, ond most oth~r blood protein ...... bHn removtd;tlltrflor~,
tilt in(idfncf 01 allflllK ~iCtioM from albumin ~ not high. Signs of alltrw indude If~~(hill" .. Ill, dyspnea, and po! libly hypott nlioo. Prott in overload may
OCQJr ij rnmive amoums of albumin i~ iofustd.
Contra indica! ions: Comraindications include It'YI'rt i ntmia or (,I rdiac: lailu~ in
the prmOU' 01 normal or in(INSfd inm'/il(ular wiullll',and allfrgy to album in.
INTERACTIONS
DIIII}-Drug: Unknown
l.i bTeru: Normal <;tItIII albumil may i"IoNsI' senJm alblint p/lospIaIR.
HerbaLlFood: lInkncwn
Treatmf nt of OYerdo,e: Therf ~ no t~atllll'llt 10rO'lfrdost.
Pregni nqc.tltgDr1(
PHARMACOKINETICS
kcau~ i lbumin ~ a natural SUbstllKf, it ~ not poIIiblf to obtain phar~netic vaws lor Wppiemfllts.
.-'
VasoconstrictorsNasopressors
In the early stages of shock, the body compensates for the
initial fall in blood pressure by activating the sympathetic
nervous system. This sympa thetic activity produces vasoconstriction, which mires blooo pressure and inc reases the
rate and force of myocardial contractions. The purpose of
TABLE29,3
Orug
Adverse Effects
dgoxinIYnaxin,~)11tl'~3.11
br~
~rhl!tmia~ AVbb:k
dobutamioe lDobuun)
epintplJine lAlRnain)
O llOl"epintphrit~l~
to reponll';l/StI.Il rang r
S-lOllKg/min
1V;0.I- O.18 mg/min until prelU~ stabilize,tbm
0.04--0.06 mglrrin for mainttnalKr
"' ~I
11~1ks
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I\J4:>irQ~M\. mgNogOfwldnru~Wrtrlliries,
OO'KlUlMI~ dro~ in blood preswrt (hypotemion
(Jf hypttlmsion)
410
Assessment
am
l.rfdGuExch.nge(cardio~J
AsItSS .,.. dtsftd thtr.Ioptlltic: effu dependent on lilt _on lor 1M drug
(t.g.. BP, pulst, wdii( OUlput rttum to witflin Jtpublt r.nge,idtquib! urine
output).
Continue frtcpJenund urtful moniloring of viuhigM,and urinar1.nd ur<b:
output iI5 appropriil~.
AsItSS"" and prOOlpl1y ~ adw-BI' dfrcti:uchyurdia, hypMmsion,
IttWtthmias,~ling ~ of mnsciOlMfI1, e.sing ~plII' .. lung
congestioft. pink4in~ frot!rt sputum, lIKrt.std urinary output,or .lltJgic
I!actions.
Implementatio n
Interve ntions and (Rllti onales)
hsuring therlpeutk effedl:
ContinU!' ~nt iI\eSIMnts IS alxnoe forthKapell'lic tffects drpmdtnl on
1M I!HOn tM drug lherapy isgMfl.(PuIst, blood pmw~.nd rtSpiralOry rate
should lit wirlIin lIOImallimits or within p.lr.1I'II!1efS set bJo 1M health Cil!
prvridtr nd ABGs andlOf pulse oximetry t1twithin ampl,ible ~mtI!rI.
(.rd'1aC output is witu. narnwl imilS and urine OUlp.ll has incrt~.)
Prome supponiYt nursing mmUftl;e.g., moistening lipsif patient is
im~ttd,~ rwtions for.n PfOlt<iurts,iIId frtqumt orienlUion.(Supportie
nUllOing muwl'l.'l Mlp 10 dMeast patirm, family, and (mgivl:f anxiety.nd
supplfI1lent the r.pruti<: drug tffr<ts to optimizr OI/Iromt..Patirnt m.y be
intubated andlor Sotdattd.)
Mini.,izing ulYerw effKls:
MoNto, for of IUd wkJlI'II! rmsS,f-9-, inuumg BP, bypert~nsion,
tact.,.Citd ii, bounding pulst, confusion. IIKrt aling 1M Iof con5iousftm.
Continue frtcpJe nt rardiK monitoring, tog, KG, and { i rdiM: output and urine
ou\jllJl (Because of 1M maul condition of tM p.llitflI: in shock.a delicatt
~Ii/l(e btlWftfl Huid voIumt tJlUIl and deficit tmu. F~uenl asstsSmtnU
musl bt madr to drtKl: .nd.void adw~ rflem. Enema! alld invasive
monitoring dmce wil dftKl: early signs of ~ ~ffrdlal Wl'1! is
mon~oring for lhe-aptlllic effrrts.)
(ae.
Fl!qVtntly monilor
Mdroiyte.aPTT..nd aPT or INR ~.((rystalloid
solJUons nwy calM elrrtrol)'te imbilincts.{oIoid solutions may mlUCt no~1
blood roagulitioft.)
LibraryPirate
(1101'1 .. 2'
Drug,forShoc:k
411
Wtigh patient d.Jily and Il'port Might gain or lou of 1kg (approximately 21b)
or mOIl' in a l (.-hour pMod.lDaily Might ~ an a((urate mNWIl' offluid siaM
and takes imo mount imake,outpu~and irunsibit Iorm.Weight gain or
l'dem~ may signall'J(i'\sil'l' lkJid l!JiJlIII'.)
E\\!luilf the eifeuiYl'll<'lI of drug tlltrapy by ronfinnill9 that patitnt goalsand eXpffied ou({omel haYl' bten ml't (Ite Plannin(].
StI' iIbIt 19.1 fIX ~ ill (/ rfIp d'r!g5 low1rtJr Ihtst 1lIIM9 <KOOIIS 1JIIII1.
Stl'1lAo MJIlingI'rocm fooJs l.tllt!,{oo{Xl111 fori1formriln rtltd !tl ~ltf'flfrykd1i(!l" ~),Qnd{III)l1'r 14flXpoIirMirrcrTopClI9"'IlI iMdi" lilt
III'IImmrliJlrod oo.
~ Prototype Drug
I Noreplnephrrne (l.evophed)
If mran sation OU\I rs, idminilter phemolam illl' to the i Il'iI of in fihration
"soon as pollibit.
00 not abrupdy disrontinue infusion.
Pll'9nanqme.;JoryD
ADVERSE EFFECTS
Noll'pilll'phrinr ~ i pov.wful \\II(I(OnllrKtor; thus, rontinuous monitorill9 of
the patitn!'I blood prffiUrt ~ Il'qU ired to prevent me deYl'lopment of h)'ptrlenlion. Whtn first admin~tt ll'd, reflex bradpn:lia ~ sometimes txperitn(ed. h
alia has !lit ability to prodlKe I\!rious typtl of dysrhythmia~ ilthough less 10
than other v.J IOpll'Isors.1i nUa"liSation O!rurs, the drug may WIIf II'rious ~in
and 10ft t~SUI' injury. Blurll'd rision and photophobia are ligns of 0YI'n:I0SI'.
Contraindi{Jtions: NOIl'pinephrifll' should not bto administered 10 patitnts
who all' exptrienc:ill9 hypottnsion d~ to blood voiuml' derKits because \\!SO(on!lriction already exists in IlJ(h patients. Noft'pin~hrifll' may cause add~
tiona!. It"Vl're periplltral and vilaral '/aI()(onllrKtion with dt<reJsed urilH'
rotput. Norepinrphrint is oot usualI)' gwen 10 patients with munterk or ptripheral mrular thrombosis, hem llf tlltre ~ ~n in(ll'ased risk of inc:lNlill9 ~
(hemia and wol1tilill9 !he infirttion.
INTERACTIONS
DrurDrug: Alpha and bmbloc:kM may iIIlligOllU 1M drug\ ~~~
ConwMy,ergol albioids and tril:yck~nl:l!lli'f po1fnti.JIt'~
PHARMACOKINETICS
LlbTeru: Uni:nown
Onset : l ~lmin
~k: l ~lmin
Treal ment of OYfrdosr: Qilrontinuill9 the infusion usw I~ ll'Iults in a rapid reYI'~I of adYl'~ rifeal mh i l hyptnrnsion.
Halflife:Unknown
Duration: Unknown
LibraryPirate
41 2
~ Prototype Drug
i
,
INOTROPIC DRUGS
Inotropic agents, also called cardiotonic drugs, increase the
force of contraction of the heart. In th" treatm~nt of shock,
they are used to increase the cardiac output. The inotropic
agents are listed in Table 29.3.
ADVERSE EFFECTS
BecalM 01 its profound elffCls on tilt caroiolllsculil, S)"Ittm, patitnll rrceiving
dopamillt must be rontinUOl.JS~ monitoft'd for signs of dysrhythmi.u and h~
~nrnsion. Ad'ieBe ~lFfCls .ft' normally ~If-limiting bec.iUI!' oltllt lhort h.lflife of tilt drug. Dopamillt is a micam drug thai can GlIM !!"11ft', ilft'Vl'rloible
skin and soft tisIII!' dam.gt if tlltdrug infihr.tts.
Contraindicationl: Dopa mine is conlraindicated in patimts with ph_hromo
cytorn. or ~mtrirular fibrillation.
INTERACTIONS
il1Jg- il1Jg:(000I"1fIl adrniislration with IMO ilhibitoo or ~ .bIoids
inmu iIIphi-.KUnerljic fiffCII. i'hfl1'!loilmay dKl&JII' OOpam Iion.1leta
bIocbrs may inhibit iIIf inotropic etJKto; 01 dopamine. AJjiw blOOM ilhibit
~1 \\IIIXDIISIriai.lligmIin and nYnY i nelillftics inclNlt iIIf rilt of
dysrh)Uwnias.
Lab TKls: lktnown
IIorbaVFoo:l: Unknown
Treatmrnt ofOYerdose: Discontinuilg tilt infusion usually ItIUIts it ripid ft'\IeIsal of idml!' effrcn such as hyprntrnion. Tht lhort--acting alpha-.ldrtoogic
bIocur plltntolamine may be administMd to lubiizt tilt patim(1 mndlion.
litter III MyMIsIniJR for aMIsJnq Prors Foo/s spKl/Ic IIIIM /trig.
PHARMACOKINETICS
il1~t: 1- 2 mil
f'eilk: Unlmov.n
Hall~ i~:2 mil
Duration: ltslilian 10 min
LibraryPirate
( ... pt .. zt
41)
o Decroa!l8d eordiae
LibraryPirate
00,,",
M .....
odilalion
.,.......
V..
Hmamine
retell""
ANAPHYLAXIS
Anaphyla:cis is a potentially fatal oonditn n in which body
defenses produce a hyperresponse to a foreign substance
known as an artligen or IIl1ergrn. On first exposure, the allergen produces no symptoms; however, the body responds
by becoming highly sensitized for a subsequent exposure.
During anaphybltis, the body responds quickly, often just
minutes after exposure to the allergen, by releasing massive
amounts of histamine and other mediaIDfS of the intlammatoryresponse. The patient mayexperitnce itching, hives,
and a tightness in the throat or chest Swell ing occurs
around the larynx, OIusing a nonproductive cough and the
voice to i>ewme hNrst. As anaphylaxis progresses. the p<I _
tient experiences a rapid fall in blood rres.sure and difficulty bruthing due to bronchoconmiction. The
hypotension c:tU5<lS reflex tachYC3rdi3. \oJithol,lt 'n,dic:tl in
tervention, anaphylaxiS leads to a profound state of shock,
which is often fatal. ~ Figure 29.3 illwtrates the symptoms
of anaphylaxis.
.--
......
Sttondloconstridicn
~ F/gU'~ 29J
Symptoms of llnaphylaxls
.-
."""....,
29.7 Pharmacotherapy
of Anaphylaxis
The pharmacotherapy of anaphylaxis is symptomatic and
involves supporting the c:trdiovascular system and prevent _
ing further hyperresponse by body defenses. Various med _
ications are used 10 trel( the SynlptOms of anaphylaxis,
depending on the severity of the SynlptOms.
Epinephrine, I: I 000, giwn suocutanoouslyor 1M, is an ini _
tial drug of choice beause it causes vasoconstriction and c:an
rapidly relieve symploms of bronchoconstriction. If necessary, the dose may be re~ated up to three times at 10_ to 15minute intervals. Crystalloids or colloids may be nt'('ded to
prevent shock if the p<ttient presents with volume depletion.
Antihistamines such as diphenhydramine (Benadryl ) maybe
administered 1M or IV to prevent further release of histamine.
A bronchodilatorsuch~ s aJbuterol (Ventolin, ProventiI) is ofI~" ;oill,ll"~t~,,,0..1 uy ;,o..IlaJ~t;u" tv rdi~"" tl ... ~~ul~ ~hurt.u~~
of breath caused by histamine release. High-flow oxygen is
lISually adminislered. Systemic g1ucocort icoids such as hy_
drocortisone are given to <bmpen the delayed inflammatory
response that may occur sew ro] hours ~fter the initial evenl.
Nearly all drugs have the ca.,..bility to allJM' anaphylaxis..
Although this isa rare adverse drug effect, the nurse must bIi'
414
ACE inhibitors
Opioid analgesics
_ Iodine_based contrast media used for radiographic exams
Although obtaining a patient history of drug allergy is
helpful in predicting some adverse drug reactions, anaphylaxis may occur without a previously reported incident.
Howevt'r, previous severe hypersensitivity to a drug is al ways a contraindication to the future use of that or closely
related drugs in the same class. Unless the drug is the only
one available to treat the patient's condition, the drug
should not be administered.
If a drug must be given for which the patient has a known
allergy, the patient may be pretreated with antihistamines or
glucocorticoids to suppress the inflammatory response. If
time permits, patit'nts may be desensitized. Desensitization
&
COMMUNITY CONSIDERATIONS
-
Recurrent Anaphylaxis
Palifnn with a history of I!(UfI!nt ~naphyluk ma~ bt prtllJibNl epin~ phrin~
10 be ~H-administ~~ imramusruLul), ia.n .utomatic: injtct.bIIo rievic:t
(EpiPm).lnl1rud thfs~ patitou 1"t9.!ding .. ~"pm lIorq.nd dilposal.nd
lilt proper injection I~(hniquf. ElKourage patients to UI~ tilt medication-flff
"tr.int( .uto~njrll pm 10 proKtic:t tht If(hn~. Advist patitnu to fXptll
som~ mrdic:.Jtion to rtm.Jin in tht pm following injection and to report.ll
~s~ requiring pm lJIa9t to thtir lIt.Jhh (.re proYider. Advis~ patitnts 10
'M'ar. medic:aI.1ert br'(fltl or IIf(kLuf stating"allerq(.nd 10carl)'.J meditation .1Ierg)' list in walltt or purse.
I Epinephrine (Adrenalm)
;<
HOME
ADVERSE EFFECTS
Tht mOSI (ommonadv~rll' effl'moftpintphrint are ne!\'OIMf"I5, trrmo~pal
pitations, ta(hyi.rdia, dizzillHs. hNdoKhe,.nd nioginglbumiog U lilt sit~ of
applic:.Jtion. Wh~n .Jdministt~ plrentt rally, hyperttnsion..Jnd dysrhythmia!
ma~ oc(ur rapidl)';thrrmrr, tilt pititm lhould he monitored wtlull)' following inj~ctiolL
Contraind i(ations: In life-threatening (onditions IIKh as.J n.phylam, th~re art
no ablOlute rontraindications forth t UIf of tpinephrint. Tilt drug must bt usf<!
with (aution, hown~~ in patitms with dysrhythmia!, U'l!brom(uiar in~lfi
(ifnI)', hyptnhyroidism, nirrow-anglt gLnKlIma, hyptrlt nsion, or (oron.1)' ~
(hemi., bK.iUII' l'pineph rilll' m.), WOI"II'n thfs!o (onditKrn.
INTERACTIONS
])ug-])ug: Epiwphrine may rKlit in h)-potfnSion ij IIItd with p/IfoothWM or
iJI)'Iodn.Thfno may bf adtitiH (Mdoasutll efIKn with OtMS~imftiG.
MAOinhibbr\ tricydk antid@p"~~B, .Jnd. iOd bfli~ ....tI
iMibit thunions of rpilfplu..... Epilll'phrine will dfmR the HlHll of b@Ii
bIotb.>rs.~9l'IlI"aI~may~thehHrttotheeffKtlof
..,n,.trint.
PHARMACOKINETICS
Q,~t 3- S min (subruianeous); S- IO min (1M)
~. k:lOmin
HalHi~: Unknown
Dur. tion:l -4h
LibraryPirate
IIerbaVFood:Untnown
Tru tmmt of Oertbsr: Ovrrdost ilia)' bf lI'riw!,.nd alpha- and beta-.HRnergic:
bIodr.trs art incicattd. Hblood pressure remains tigh,. 'I<lIOdiator IN)' be adminintrrd.
~~ Chapter REVIEW
KEY CONCEPTS
The numbered ko!y cOIKept5 provide
5uiO(:1 summary of the important poinlS from the corresponding numbered se<:tion
within the chapter. If any of these points art DOt deu, ref.. r \0 the numbered sectIo n within th e chapter for review.
29.1 Shock isa clinIcal syndrome characterized by the lnabUity
lar systems.
29l Shock is often dassified by the underlying pathologic
process or by tile organ system thai Is prirmrily affected,
NCLEX-RNOREVIEW QUESTIONS
The patient in hypovolemic shod: is prescribed an Infusion of lacmed Ringer's. The nurse recognizes the func
tion of this fluId In the treatment of shock is to: (Select all
that apply.)
1. replace fluid and promote urine output.
2. drawWllter into cells.
}. draw water from cells to blood ~ls.
4. maintain vascubr voIUIJlt'.
]. Unuswl bleeding
2. Hypeiilytemia
}. Anaphybctic reaction
4. Hypotension
LibraryPirate
4. ~ of oonsdoumes:s..
5. aPTT, aPT, INR
416
UIIII.4
OPlORE
~, .-------,
... y....ingKll i;}'(IlI" IDI skip lor orb dl<ipl8r '"",,"'N malt',ials ;nj
'esGUa!S. Preptre tor 3lI= with ilddiliooaJ NCLW-9lyIe p"";Ii;e
qlJes!lOns. (rte<actroe assigrvrenls and ""trollies. wtII hks. animm;
Itld vidoos, and JTlQfe!
-.-.mynursift9kjt.com.
LibraryPirate
Chapter 30
Diuretic Therapy and Drugs
for Renal Failure
DRUGS AT A GLANCE
LEARNING OUTCOMES
LOOP DIURETICS
pl/l/tfJI
THIAZIDE DIURETICS
pillJt411
POTASSIUMSPARING DIURETICS
ftl9t41J
o splronoIaCfOf'Ml(ll/OOC/OOfj ".4].1
MISCELLANEOUS DIURETICS
Pfl9t414
/D}t42S
KEY TERMS
diu~tK poIjf420
nfphron Jf1Jf418
rfablorplion ptJI}t4l!
fi~r.tf ~m
rmalf~ikn plJ/t418
mbonknh,drnt
ptlI}t414
LibraryPirate
~rttion {1Jgt m
urinllylis
(!I19t4ll
418
U""~
used to treat kidney failure. Chapter 3100 presents iKlditlonal agents for treating fluid, electrolyte, lind acid - basI.'
Imbalances.
"
Whfn most proplf think ofthf kidnf}'S, they think of excretion. Although this is certainly true. the kid neys have many
other oolTlC05t>.lic fur>ction ... lbc kidlK)'Jar( th( primaryo
gans for regulating fluid balance. eiedrolytecomposition, and
acid--trase baJall(eofbodyHWds. They also secrete the enzyme
renin, whKh helps regula!e blood pressure (cha pter 2)00 )
and erythropoietin, a hormone that stimulat es red blood
cell productio n (chapter 2800). In additi on, the kidneys
are respo nsible for the production of calcitrio l, the active
form of vit~ min 0, which helps maintain bone homeostasis
(chapter 47OJ11: .1t is not surprising th~t our overall heaLth
is st rongly dependent on proper functioning o f the kidneys.
The urinary system consists of two kidneys, two ureters,
one urinary b13dder, and a urethra. Each kidney co ntains
more than I million Mphrom, the functio nal un its of the
kidney. Blood enters the nephron through the large renal
arteries and is filtered through a semi pe rm eable membrane known as the glomerulu s. Water and o ther small
molec ul es re:a dily pa5S through the glomerulus and ('Iuer
Bowman's capsule, the first section of th e nephron, and
th en th e proximal tubule. Once in th e neph ro n, the fluid
is called filtritte. After leaving the proximal tubule, the filtrate travels through the loop of Henle and, subsequently,
the di stal tubule. Nephrons empty their filtrate into common co llecting ducts, and then into large r 3nd larger collec ting s tructures inside the kidney. Auid lu ving the
collecting du.::ts a nd entering subsequent porlio ns of the
kidney is called urine. Parts of the nephron ar~ illustrated
in .. Figure 30.1.
Renal Disorders
A~hcugh mOl't tIIon 17,000 kidney trlnlf'lanb Irt perfonntd Inn~11):
mort thin 70.000 PfopIr arton a Witting I~t lor I rtplictment kidlle1.
Oneof f'lelY 750 ptOplt ~ bom with a linglt kidlle1.A~nglt kidney ~
largtr and mort \\llnrratk!O injuryfrom he,nyl.mct lpotts.
LibraryPirate
Many drugs are small eno ugh to pass through the pores
of the giome rulusand enter the filtrate. If the drus is bound
to p13sma protei ns, however, il will be too la rge, and will
continue circulating in the blood.
RENAL FAILURE
iltlallaillR is a decrease in the kidneys' ability to maintain
electrolyte and fl uid balance and to excrete WlIste products.
The caue of renal failure may be due to pathology within
the kidney itself o r the result of disorders in other body systems. The primary treatment goals for a patient with renal
failure are to maintain blood flow through the kidneys and
adequate urine output.
P9rmbwlr
'--~~"
GlomerU,,"
arta."
."o.m.
tubul.
--
419
To blltdder and
To """,I
"";n
eldernal enviromant
FlgureJO.I Thenephron
which examines urine for the presence of blood cells, proteins, pH, specific gravity, ketones, glucose, and microorganisms. The urinalysis can detect proteinuria and albuminuria,
which are the primary measures of structural kidney damage. Although it is easy to perform, the urinalysis is nonspecific: Many diseases can cause abnormal urinalysis values.
Serum creatinine is an additional measure for detecting kidney disease. To provide a more definitive diagnosis, diagnostic imaging such as computed tomography, sonography, or
magnetic resonance imaging may be necessary. Renal biopsy
may be performed to obtain a more specific diagnosis.
The best marker for estimating kidney function is the
glomerular filtration rate (GFR), which is the volume of ftltrate passing through Bowman capsules per minute. The
GFR can be used to predict the onset and progression of
kidney failure, and provides an indication of the ability of
the kidneys to excrete drugs from the body. A progressive
decline in GFR indicates a decline in the nwnber of functioning nephrons. As nephrons "die," however, the remaining healthy nephrons have the ability to compensate by
increasing their ftl l ration capacity. Thus, patients with significant kidney damage may exhibit no ~ymptollls wltil
50% or more of the nephrons have"died and the GFR falls
to less than half its normal value.
Renal failure is classified as acute or chronic, depending
on its onset. Acute renal failure requires immediate treatment because retention of nitrogenous waste products in the
body such as urea and creatinine can result in death if Wl
treated. The most frequent cause of acute renal failure is renal hypoperfusion, which is lack of sufficient blood flow
AmphomidoB
SySlmic:Jotiflllgal infffiioo
Angiotrnsin-<onl'l'rling ffil)'IIIt
lACE) iohi~lOO
(i5pIa!inkarbopl~tin
LibraryPirate
Viral iofffiioo
Nonsteroidal ~oti infliOTnJttwy
Inllimmi!ion
d'ugs INSAIIlI)
Prntamid~
4 20
DIURETICS
Diuretics are drugs that alter the volume andlor composition of body tluids. They are indicated for the treatment of
HTN, heart failure, and disorders characterized byaccwnuIation of edema fluid.
Hypertension
Heart failure
Kidney failure
Liver failure or cirrhosis
Pulmonary edema
The most conunon mechanism by which diuretics act is
by blocking sodium (Na +) reabsorption in the nephron,
thus sending more Na ~ to the urine. Chloride ioru (CI- )
follow sodium. Because water molecules also travel with
sodium ions, blocking the reabsorption of Na ~ will increase
the volume of urination, or diuresis. Diuretics may affect
the renal excretion of other ions, including magnesium,
potassium, phosphate, calcium, and bicarbonate ions.
Diuretics are clar.sified into three major groups, and one
mis.:ellaneous group, based on differences in their chemical
structures and mechanism of action. Some drugs, such as
furosemide (Lasix), act by preventing the reabsorption of Na ~
in the loop of Henle; thus, they are called loop diuretics. Because of the abWldance of Na ~ in the f.iltrate within the loop
of Henle, drugs in this class are capable of producing large inueasesin urine output. Otherdrugs, such as the thiazides, act
by blocking Na ~ in the distal tubule. Because most Na ~ has already been reabsorbed from the filtrate by the time it reaches
the distal tubule, the thiazides produce less diuresis than
furosemide and other loop diuretics. The third major clar.s is
named potassium sparing, because these diuretics have minimal effect on potassium ( K~ ) excretion. Miscellaneous agents
include the osmotic diuretics and carbonic anhydrase in hibitors. Thesites in the nephron at which thevariousdiuret
ics act are shown in Pharmacotherapy Illustrated 30.1.
.....
Pathogenesis
Treatmrot
H)"pt!blrmia
H~Im1ia
HypmoIrmia
Comphcatlon
H)"pOUktmiil
Mmbolk addosis
LibraryPirate
(lIopltllO
42 1
PHARMACOTHERAPY ILLUSTRATED
30.1 Mechanisms of Action of Diu retics
o.molic di_;'"
Act on the pruoojmaI tubu'" .00 !he ""'" of
Henle, to create an 0Im0Iic fore. thai pub
water ;"10 the
,Old i~ Ihe
aliiolectrolyl_
Thiazide diu..-!K:.
Act on !he 68I1y <Hlsllubule 10
block !he reabIorplion of .odium.
chloride. and water. E><cretion 01
pot ....... m ;. Wlcreued.
".....
EIWIy distill
..
loop diuretic,
JIw:t on the ~ng Ii"*' of the loop
of Henle to block !he ~Iion 01
.odium, chloride .,d
Excretion
of ~ 1.1nc....M<i
w,'.
po~
....mg diuretic.
30.S Pharmacotherapy
with Loop Diuretics
The most effective diuretic; are the loop or high-l'eiling di
uretic;. Drugs in this class act by blocking the reabsorption
LibraryPirate
of Na" and Cl- in Ihe loop of Henle. When givt'n IV, Ihey
have the ability 10 cause large amoWlts of fluid to be excreted by the kidney in a very short time. loop diuretics are
used to reduce the edema associated with heart failure, hepatic cirrhosis, or chronic renal failure. Furosemide and
torsemid ea re also approved for HTN. Doses for the loop diuretics are listed in Table 30.3.
Furosemide is the most frequen tly prescribed loop diuretic. A prototype fealure for furosemide was given in
chapter 2400 . Unlike the thiazide diuretic.s, furosemide is
able to increase urine output even when blood flow to the
kidneys is diminished, which makes it of particular value in
patients with renal f.lilure. Torsemide has a longer half-life
than furosemide, which offers the advanl<lge of once-a-day
dosing. Bumelanide (Bumex) is 40 times more potent than
furosemide but has a stwrter duration of action.
The rapid excretion of large amoWlts of fluid has the p0tential to produce serious advt'rse effects, including deh~ra
lion and electrolyte imbalancel.Signs of dehydration include
thirst, dry mouth, weight loss, and headache. Hypotension,
dizziness, and fainting can result from the rapid Huid loss.
Potassium depletion can be serious and cause dysrltythmias;
422
UnII4
(Bum!'lj
Adverse Effects
t1hKrynicadd (Ett:uinl
~0I5ffi1~ (Dmladu)
='
potassiwn supplements mar be prescribed to prevent hypokalemia. Potassium loss isof particular concern to patients
who are also taking digoxin (Lanoxin) because these patients
may experience dysrhythmias. Although rare, ototoxicity is
possible, and other ototoxic drugs such as the aminoglycoside
antibiotics should be avoided during loop diuretic therapy.
Because of the potential for serious adverse etfects, the loop
diuretics are normally reserved for patients with moderate to
severe fluid retention, or when other diuretics have failed to
achieve therapeutic goals.
30.6 Pharmacotherapy
with Thiazide Diuretics
The thiazides constitute the largest, most frequently pre
scribed class of diuretics. These drugs act on the distal tubule
to block Na + reabsorption and increase K+ and water excre
TABLE 30.4
tion. Their primary use is for the treatment of mild to moderate hypertension; however, they are also indicated for edema
due to mild to moderate heart failure, liver failure, and renal
failure. They are less etfective at producing diuresis than the
loop diuretics and they are inetfective in patients with severe
renal failure. The thiazide diuretics are listed in Table 3004.
All the thiazide diuretics are available by the oral route
and have equivalent efficacy and safety profIles. They dif
fer, however, in their potency and duration of action.
Three drugs--chlorthalidone (Hygroton ), indapamide
(Lozol ), and metolazone (Zaroxolyn )--are not true thiazides, although they are included with this drug class be
cause they have similar mechanisms of action and adverse
etfects.
The adverse effects ofthiazides are similar to those of the
loop diuretics, though their frequency is less, and they do
not cause ototoxicity. Dehydration and excessive loss of
Drug
Advel"le Effects
Mioorhypcko /mlio, ~
SHORT ACTING
Q
dllorothiilidt (Dillil)
h)'ltodllorothialilr (Mirroz~)
(5e~ piljt 304 for th ~ Proiotypt
LONG ACTING
ind.Jpimidt (LmoI)
1'0; 1.5- 10fll9lday (max: 5mgtdol)' for HTN; I0fll9lday for ~delllil)
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Signifi9nl hypobl..,io.
d~plelioo. dehydr.lfon
tIKi.
hypotension.
"""'"
Cll.1pt0l30
~.
Prototype Drug
423
the body retains more K+. Because most of the Na + has already been removed before the ftltrate reaches the distal
tubule, th ese potassium-sparing diuretics produce only a
mild diuresis. Their primary use is in combination with thiazide or loop diuretics to minimize potassium loss.
The third potassium-sparing diuretic, spironolactone,
acts by blocking the actions of the hormone aldosterone. It
is sometimes called an aldosterone antagonist, and may be
used to treat hyperaldosteronism. Blocking aldosterone
enhances the excretion of Na + and the retention of K+. Like
the other two drugs in this diuretic class, spironolactone
produces only a weak diuresis. Unlike the other two,
spironolactone has been found to significantly reduce
mortality in patients with heart failure (chapter 2400 ).
Eplerenone (Inspra ) is a newer aldosterone antagonist
that is claimed to exhibit fewer adverse effects than
spironolactone.
Patients taking potassium-sparing diuretics should not
take potassiwn supplements or be advised to add potassiumrich foods to their diet. Intake of excess potassiwn when taking these medications may lead to hyperkalemia.
I Chlorothlazlde (Dlunl)
ADVERSE EFFECTS
Ur:tssioss of w'ter and ~ledrolytfS can i)((lJr during chlorothi.uide phlN(otlil'rap)'. Symptoms ioc:Ude miBt, 'ftam~ I!>thargy, mUl(I!> (lamping. hypolfnsion,and tac:hyutdii. lieuUS!' of thf polfmially sfrious {onlf~t-! of
hypokiltmia, pltienn (ooc:urrrmly takillC) digoxin should be utclully mon~
tored. Thf intlke of polas~um-rKh foods should be ilKru!l'd, and K~ suppltmenll may be indicalfd.
Co ntraindi alli ons: This drug is (ontraindiutfd in ~Iifnll with anuria,
hypokaltmiJ, Sf"lfll' hepni( or II'nal im~irmfnt. and hYPf llensitiviry 10
sulfonamide-!.
PHARMACOKINETICS
On~ : 2h
PO;lS min IV
~k: l~h
PO;30 min IV
Halflif! : 45- 120 min
~n: 6-llhPO;2hlV
INTERACTIONS
DnJ}-D"'l: WhMg ..... ,onrmmtywilhotluor ilnlih)'lW'fl...u."\ odIiI .... PIfIorn
on tmd preIlln wil OUII".Wh@ndllonlthiazidfisadmir:i:lK>lHlwithMnphotflil:il
LibraryPirate
424
UnII4
TABLE30.S
Drug
The
(~,dloYaKub,.oo
Urinary Synefm
Potassium-Sparing Diur"tics
Routeand Adult IJosio (maxdo5e where Indicated)
Adver5e Effects
tplmIIOfN' (lmpra)
1'O;1,- SO mgOlKtdaiy [max: 100 mgldolY fof HTN;SO m9i'doJY for hun faiull')
1'0;1,- 100 mg 1-1 timffidoJY (mu; 400 mglday)
1'O;'iO-100 mg bid (mu; 300 mglday)
gynK0/I1Q5Iio
"
SjiItW'dlOllt (AldiClmt)
triamtmot (Dyrrnium)
I Spironolactone (Aldactone)
i
,
o
ADVERSE EFFECTS
Spirooolmolll' does such an ffficifm job of lI'I'ining K~ that hyptrbltmg
lI\Iy r1tvtlop. TIlt risk ofhyptrbltm;, is inmased if the palil'llt tlkts potassium
supplemtnts or is (OIKUl1l'IIt~ taking ACE inhibitors.. Signs ,nd symptoms of hy
ptrblemia include mus<1e Wt'aklll'ss, fuigut, I nd bridyu rdi'.l nm~n, spirooo
laaolll'un CilUgYlII'ComiStia, impot~n(t,and diminished libido. '&I11I'II m,y
uptfifnu IIII'IIItrual illl'9uiaritifs, himrtism, anc! bll'lSI ttnlierlll'lS. When
serum potassium levtls III' monitoll'd ull'ful~ ind lI\Iinrained within oormal
v,lutl,ad~ tffKtS from spirooow(tolll'ar~ ulI(ommon.
Contraindications: Spirooola(tolll' is romraindiuled in patitms with anuria,
significanl impairm~m of II'MI function, or hypmalemg. SpironoL!dont is
rontraindiuted during Pll'9nancy and LKtilion .
INT ERACTIONS
1AlJg- 1AlJg: 'M1Hr~~~ MIlt ammonirn <IIIotiM,iICidoIis
m.Jf !KCUL Aspirin and 0IhH s.alicylar:1'I m.Jf droNse thr riu"flK ~lIea of the
mtdication. (oocUJltfllllll' with digoxin m.Jf dooNSf 1l1li' IIIi'm of digcl;i1. WIlI'I1
ubn with potlS~um ~ts,ACE inhibitoo,and ARBs.h)llffb1ernj, II\I'f
rtIUt. (orKIUlmtllll' with illllih)"pl'l'1el"6im wit R'lUk in an addiIi"lf hypotalli"lf
"'~
PHARMACOKINETICS
iAlset: 1- 2days
Pl!ak;1- ldays
Lab lests:SpironoLKtOlll' m.Jf i KIUlf ~1fIIiI cortisol nlkli'l, and m.Jf n~1
wfth IffIIm gllKOIt dflHrllinalion.
Half~ifto:12-14h
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(1101'1,,10
42S
0""
Adverse Effects
(Neptll.Jnt)
PO;l50-l75mglday
PO;SI>-I00 mg bid-tid
maoo~d (Ow~roI)
Hyponalltrllia
ulI'i(Uruphij
~i ronl'Jlsion~ @dMalliia
Assess me nt
~Ianle.
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426
En lUre p.1I~nt saftl)', tspt<ially in the tIdtrIy. ObS!'1'fI' for diuilll'!5. Monitor
Imbulation until tlfttt.of drug alt' known.(Diuinffi from OrthoStltK
hypottnrion nwy oc(ur.)
Wtigh the p.1Iient dail)- and It'port significant ~ight ljiIin,or Io.~ Mt.tsurt
intlbo and output in the horpiulill'll p.tt~m.(Daily wright ~ an H(Uratt
rntiIsu .. of fluid ,tlIUI il nd ubos intoatcount inuk~ OUIpul,lnd in!!'lllibk
1os~.Diu~~ is indicated by outputlignirKilntly g..attr than intikt.)
Tum rho
10 from lying o ining to "ilnding <lowl)- to
.woid
diuinffi or falls.
p"~m
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ri
-,.
(Continued)
Implementation
Interve nti ons and (Ratio nalu)
ARBs may ifl(rtasr IIIr risk of hYfll.'rblemw .CDncu~t UIt with digoxin
incfll!asts lilt risk of poteolwily fatal dysJbythmiM and COIICIJfftnt list witb
lilhium may OOIt tOllie 1Mb of the dNg.1
Ot-w for Ii9n sof hyperglyumii. Ust with caution in patirnl5 ...nth di.lbetts.
(Thiazide, Ihiazide..lilo:t, ind loop diurtrics may aIIsr hyptl9l)'Ctmia,t~iilty
in cliibHics.)
Ob_ for sq. s of infeion. (Somediurrlics may dKrtl\e white blood cell
counts. Agrinulocytosis is a possille ~ effm of diuretic thtiapy.)
disruplion of sftpfromnocturia.(PropeI.inistrltionincrtueslllt
tffI1vrIltsS of the drug.)
EVlLluatlon of Outcome Criteria
Evalll.Jl~ tM
rfWti'lmtSl 01 drug IflrriPJ by ronfirmillll Ilia! patRnt 00i1l otrId Bpt(Ird out{om~11Y1'I' been flll'1(see1'lanninl(l.
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4 28
&
COMMUNITY CONSID~RATIONS
---
KEY CONCEPTS
The [Jumi.>t:roo k.ey
~u[J,""plli
provio.l"
~ su~d[J~1
SUflJHtary uf Ihe
iHlpur1~[J1
nUHli.>t:roo ""-lion
within the chapter. If any of these points are not clear, refer to the nWllbered section within the chapter for review.
30.1 The kidnt'ys regulate fluid ,"Olume, ele.;:trolytes, and
acid-baSt' baianCt'.
maintain urine output while the cauSt' of the renal im pairment is treated.
distal tubule of the nephron, and are the most widely presc ribed class of diuretics.
sparing diuretics are used in combination with other
agents, and help pre'en! hypokalemia.
30.8 Several less commonly prescribed classes such as the os-
Which of tht' following actions by the nurSt' is most im portant when caring for a patient with renal diSt'aSt'?
1. Identify medications thm have the potential for
nephrotoxicity.
2. Check the specific gravity of the urine daily.
3. Eliminate potassium-rich foods from the diet.
4. EncOllI"llSt' the patient to ,oid every 4 hours.
4. Sodium
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(1101'1 .. 30
Which of the following clinical manifestations may indi ,ate the patient is experiendng hypokalemia?
I. Hypertension
2. Polydipsia
3. Cardia, dysrhythmias
4. Diarrhea
II
429
J. A 17-year-old male patient is admitted to the ICU following a car-train collision. The patient sustained a depressed
skull fra,ture and ison a ventilator. Twodays after surgery,
there are obvious signs of in,reasing intra,ranial pressure.
The nurse administers 32 g of a 15% solution of mannitol
(Osmitrol) per IV over 30 minutes. The patient's mother
asks the nurse to explain why her son needs this drug.
What explanation should the nurse offer?
EXPLORE
~.-----,
M)'Nursi1gKiI is YOUI OIl! stop for orIiO! chaple, 1l!V;!W materials and
"'iOU'CII .. P!apar~ for S!ICC\!I&S with additiorl3l 11ClEX"$\yIe pr.u;li c&
QU!S1ilns. InteractM! assI g nm~ nts ani actlllltfes, web finks, anlrnatOO.
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Chapter 31
Drugs for Fluid Balance,
Electrolyte, and
Acid-Base Disorders
DRUGS AT A GLANCE
LEARNING OUTCOMES
Q dexrron40(Genlron40,orhl'f'5) pagtm
ElECTROlYTES PIX1f36
fII1jf4J9
ACID-BASEAGENTS pu;t4J
Q miumblcQrbonore JUjtW
KEY TERMS
icidosi! JUj/440
.Ikalosis p!lgf I
.nion f!lHJ"4J,
buffer {X!qt 440
cation {!a/t436
colloids pltjt4J6
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3.
4.
S.
6.
(rystalloids pq m
electrolytes pq436
extr.IC.llular fluid IEeF) compartment
hyperkalemia PJI/I'4J8
hypernatremia po:JI437
hypokalemia pq438
filN}t4l1
hyponatremia pq 437
intra(enularfluid (ICF) companment PJI/I'431
o.moblity filN}t4Jl
osmosis PJI/I'4lI
pH fOJ14-I(J
tonicity pi!rJl431
31 .2 Osmolality, Tonicity,
FLUID BALANCE
Body fluids travel between compa rtments, which are separated by semipermeable membranes. Control of water balance in the varioIU oompa n ments is e:ssenti:al to
homeostasis. Auid imbalances are frequent indit:ltions for
pharmacotherapy.
-~
lnltlntilial
Iuid: 12l
Celt: 2S l
.......,
3l
"
"
"
,
""'
,, ,
,,
m
, ,
, "
,
m
"
m
C>OITIPI'Itrr...-.r:
a>rnpmrtmenI
body -...ighI
~ c/ body weigl!
FlgunJI.1 MaJor fluid compartmPnts In the body
M)'JI. of
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Osmolality and tonicit y are two related terms central to un derstanding fluid balance in the body. Large changes in the
osmolality or tonicity of a body fluid can call.>;e significan t
shifts in water balance between compartments. The nurse
will often administer IV fluids to compensate for these
changes.
The osmolality of a nuid is determined by the number of
dissolved partides, or so lut es, in 1 k~ (I L) of water. In most
body fluids , three solutes determine the osmolality: sodium,
glucose, and urea. Sodium is the greatest contributor to osmolality due to ilSabundance in most body fluids. The normal osmolality o f body fluids r:anges from 275 to
295 milliosmols j>eI" kilogram (mOsmlkg).
The term 100iOtJ is sometimes used interchangeably with
osmolality, althou gh they are somewhat different. Tonicit y
is the ability of a solution to ca u~ a mange in water movement across a membran e due loosmotic forces. 'Vhereasos molality is a laboratory value that can be pre<isely
measured, tonicity is a general term used to describe the
relative concentration of IV fluids. The tonicity of the
plasma is used as the reference point when administering IV
solutioru;: NorflUll plasma is considered isotonic. Solutions
that are isotonic howe the same concentration of solutes
(s.ameosmolality) as plasma. Hyp",onicsolutions (ontain a
greater concentration of solutes than plaSflUl, where;ls
hypotonic solutions have a lesser concentration of solutes
than plasma.
Through 0IIIIIni1o water moves from areas of low solute
concentrat ion (low osmolalit y), to arta s of high solute
con(~ntration (hi gh osmolality). lfa hyparon;c ( hyp erosmolar) IV solution is admini stered , the plasma gains more
solutes than the interstitial fluid. Water wiD move, by osmosis, from the interstitial fluid co mpartme nt to the
plasma wmpartmenl. This type of fluid shift removes water from cells and can result in dehyd ration. Water will
move in the opposite direction, from plasflUl to interstitial
fluid, if a h,paronic solution is adminis tered. This type of
fluid shift could res ult in hypotension due to mo'em en t of
water out of the vasc ular sys tem . Isotonic solutions will
produce no net fluid shift. These movements are illustrated in .. Figure 3 1.2.
4]2
UnII4
The
(~,dloYaKu b ,.oo
Type of
Movement of Fluid
infusion
~
:/- ~
.. .... 11' ..
l.o,rnw
------ .
io
plasms
,
~
R uR
.. '" solute
(a) Isotonic
Urinary Synefm
(b) Hyper10nic
I_MOO
"'~
(c) Hypotonic
.'.
. "'"
,
.. Flgurell.2
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01 ..11., lt
433
Tonicity
Isotonic
I/ypI'rtorir
Hypotorir
LKtattd Ringtr's
Isotonic
Plilmt-Lytl' 148
Isotonic
Plilmt-Lytl' S6
Hypotorir
DEXTROSESOLUTK)NS
S% 0011011' in Wittf lDSW)
Isotonic"
I/ypI'rtonir
kotonic:
Hypl'rtonir
Hypl'rtonir
S% ootrw in ~{yt~ 56
* ~ ~111_ ~
Irjpotorir.
PHARMACOKINETICS
OnW'!:wral minutes
PNk:Unknown
Halflife:Unknown
Duration: 12-24 h
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ADVERSE EFFECTS
ViLli sign! should be monitom:l continUOUlly during dau,n 40 infu!ions to
prt'I~nt hypMl'nwn WIsed by pla,m. voIumt npan>ion. Signs oIlIuid MrINd indude tar:h-,urdia, pl'riplltr.1 tdtma,distl'nded n~<k ''ins,~pnN,or
raugh. A>m.1I pMtntagt of palitonu.~ . n~rgir 10 dextran 40, with urtiuria
being the mo>l (ommon ,ign.
INTERACTIONS
Dru;rDrug: ThHtn nodiirMIy ~nbt intHaaions.
HerlIaVFood: Unknown
TlNtmtnt ofDvrrdo~: For pi!~rm with oormal ft'n.1 funrtion,dis<ontirwtion oftht infusion will mull in rtdunionof .Mrse ~ffKH.Pati~nu wilh rl'nal
imp,irmtnt rrwy bellern from tilt admin~tr.llion 01 an osmotic: diufttK.
It!(pf ro M)Nunllrgm for Q Nunlnlj I'rfKnj fOOIllpKlk ro rIr/s dnJlj
4] 4
REPLACEMENT THERAPY
Assessme nt
Derlci~n1
Fluid Volumt
. ht~
Activity Intoleranc:e
DefKitm KIIO"II'Itdgt (drug thtrapy)
Rilk 101 Falb, Risk Iollnjury (related to il)opottnlion, dizrines'aI!O(iated
with .a.ersr tfkts)
Risk 101 Enmive Fluid Volume (~latN todrug thflapy)
Risk lor In~ff~til'f Hfilth Mainteoan~ (~arding drug eflemand dittary
neeik)
LibraryPirate
m.imainilg I
Instruct tht ~titnt on tilt IIffil to mum ptriodic.Jl~ for LIb worlc
kr."of 1kg
21b) 01 min in a 24hour period.(D~ily weight is an
i(urat. meilU~ of Auid status and takl's imo .({oom intake, OUlput.and
insensiblt Iolle. kight gain oredfmll may lignala{5~1If fluid tIUIlK'
ortlffirolyt. imbaLlIKf1..)
(applOlimatt~
Ttam tht patifm to tilt from lying or ~ning to standing slow~ to.woid
diuinm orfalls.
Instruct thf ~titnt to ull for ulistan{~ prior togming out of bed or
attempting tow,lk alolll'"nd to avoid dri'ling or other aaivitifl requiring
mental a!tnlltllor ph)"lilal (oordination if I"ftded.
p4titllt wrigh Idf d.il" 0011, 4tth... n", timf uf d. ".nd ....
H.ov.
weight along with blood
and
mmUren1ffill.Hallf tilt
~'f
urtI
prt\Su~
pu~
The p;atitn~ family, or uregiVl'l should bt ablt to state the re,l\on for the
LibraryPirate
436
UnII4
TheC~,dloYascul~,
li
ElECTROLYTES
Eledrolytes are small charged mole-cules essential to
homeostasis. Too little or 100 much of an electrolyte can
TABLE 31 .3
""00
DNg
Tonicity
Compound
Formula
Cation
S%,lbumin
"'ro'
uki!Jltdl~
y~
yo.
Isotonic
llMdium~t~
""HPO.
Isotonic
Ptltmi!Jlt dIIorido!
'"
",itCO,
~.
~a
~.
0-
~,50.
",.
'N
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....
..
"'
"'
"'
--..
5Id!IIt biYrbonaIt
,.
",.
l(J-
HPOl"
0HCO,-
OI..,l<r 31 Drug' for Auld Balane... E1ec:rrolyl ... , 00 Acld-tl .... 01so<d .."
437
Supportive Treatment"
IIyptrGikrrri.J
,11
<,
C.ki!lllll.Wltm~n1Sor wilMnil 0
'"-
Hypouknnii
Hyptrdllmmia
>112
Hypotoric ftuid
I/ypodlIlKflIIia
<95
MilgnciJm
lIyptrmig~ia
"<"
Hypotoric ftuid
"
"
""
Caki!lll
H)'pOIIU9nNmii
Pho5phal~
Hypt~lt111ia
Hypoplmphillemi'
Ptu,si!lll
Hyptrkiirrnia
Hypobirrnii
Sodi!lll
H~rnanmii
Ilyponatrtmia
<1
<35
I >145
"'us
31 .6 Pharmacotherapy
of Sodium Imbalances
Sodium is the major electrolyte in extracellular fluid. Because of sodium's central roles in neuromuscular phy5iology,
acid- base balance,and overall fluid distribution, sodiwn imbalances can have serious consequences. Although definite
sodiwn monitors or sensors have yet to be diswvered in the
body, the reguJ.1tion ofsodiwn balance is well understood.
Sodium balance and water balance are intimately wnnected. As Na+ levels increase in a body fluid, solute particles accrnnulate, and the osmolality increases. Water will
move toward this area of relatively high osmolality. In simplest terms, water travels toward or with Na+. The physiologic wnsequences of this relationship cannot be
overstated: As the Na+ and water wntent of plasma increases, 00 does blood volume and blood pressure. Thus,
Na+ movement provides an important link between water
retention, blood volume, and blood pressure.
In healthy individuals, oodiwn intake is equal to sodium
output, which is regulated by the kidneys. High levels of aldosterone secreted by the adrenal wrtex promote Na + and
water retention by the kidneys, as well as K+ excretion. Inhibition of aldosterone promotes oodium and water excretion.
When a patient ingests high amounts of oodiwn, aldosterone secretion decreases, thus allow ing excess Na+ enter
the urine. This relationship is illustrated in ~ Figure 31 .3.
Sodiwn excess, or hl'Pfrnatremia, occurs when the serum
sodium level rises abo~ 145 mEq/L The most wmmon
cause of hypernatremia is decreased Na + excretion, due to
kidney pathology. Hypernatremia may also be caused by excessive imake of sodiwn, either through dietary conswnption
or by overtreatment with IV fluids wntaining sodirnn chloride or sodiwn bicarbonate. Another cause of hypernatremia
is high net water losses, such as occur from inadequate water
intake, watery diarrhea, fever, or burns. High doses of glucorortiwids or estrogens also promote Na-+ retention_
LibraryPirate
~nni!llllUppItmmB
4] 8
Sy""'"'
I loa_sed K+ excretion I
~
HOME
&
COMMUNITY CONSIDERATIONS
31.7 Pharmacotherapy
of Potassium Imbalances
Potassium, the most abundant intracellular cation, serves
important roles in regulating intracellular osmolality and in
maintaining acid- base balance. Potassium levels must be
carefully balanced between adequate dietary intake and renal excretion. Like Na+ excretion, K+ excrelion is influenced
by the actions of aldosterone on the kidney. In fact, the renal excretion of Na + and K+ ions is closely linked- for
every sodium ion that is reabsorbed, one potassiwn ion is
secreted into the renal tubules. Serum potassiwn levels must
be maintained within narrow limits. Both hyper- and hypokalemia are associated with fatal dysrhythmias and serious neuromuscular disorders.
LibraryPirate
Adl'!'~ t ffts
~ Prototype Drug
ADVERSE EFFECTS
P.tifnu Il'criYing /laCI infusions must bt monitortd frequenlly to p~m
symptoms 01 hypmlallt'lllia, which ilKludt letharg)', confusion,muscit 1remor
or rigidity, hypotension,and rtstltssnflS. ~UII' SOliii' of thl'lf symptoms . 1l'
.150 {ommon 10 hyponatll'mia, ~iodic lab oHlI'Ssml'nt, must bt lakt'n 10 bt
(I'Main sodium .J Utslie within 1M oorm.1 n!/t. When infusing 1% NaClsoiutions, tht flJllt m uld continuous ~ {hfckfor signs of pulmOllilry I'dtlN.
Contraindications: Th~ drug should 001 lit adminisll1ll'd 10 p.atients with hyptmUIl'fII Y, {oogesti'll' hurt failull',o. imjli irtd 1l'nallulKtion.
INTERACTIONS
Dru;rDrug: Thtrf aff oodi1icilily lignnl dfUl inli'fiKtions.
li b115ts: l.o!ium dl10ridf inaNsfs thf IfIIJIl sodiJm 1fflI.
HerliallFood: Unknown
PHARMACOKINETICS
~UII' sodium chloridt ~ a nalur.lsubstalKf, phillllloKokilll'tic dol1a
ul'diffiruk to oblain.
439
Treatment of Omdo Sf: Iffluid accumulation occurs rut 10 a U'S, sodiJm, diUrtlin may bt admin~tell'd to Il'ciKl' pulmonary or ptriplltral tdtma.
.... ter III M)Nuflln9l for Q NurIifIIJ I'rrKm fIK1l'i JjItdk III rIr/s dfI!9.
PHARMACOKINETICS
StaUIl' potalSium {hloridt ~ . nalUlalsubstalKf, pha'IN{oi:inelic dati
.J~ diffiruktooblain.
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ADVERSE EFFECTS
Nausu arod I'Omiting a~ {ommon, btcaUSt polmiJm (hlorid!' initalts the GI
muro!a. The drug may lit t.lk!'ll with meals or anloKids 10 itsll'll ganric distlflS.
Tht most serious adl'ff"ll' rifo{ts 01 potassium (hlorid!' .J1l' ll'Iated 10 the POII~
bie acrulllJl'lion of m tsl K+. I-/yptrblemia molYoaur if thl' patient lakes
pot.ssium suppltments rolKU~ntly with potmum-sjliring diull'tiu. IkLJ!/lt tllt kidnl')'lptriorm mo~ thin 90% oflhl' body, potassium eJ(rttion,~
duct<! ~rwllunrtion can rapidly itad 10 hyptflcaitmia, p.rticularly in patients
uki",! potmiJm!Upplern~u.
Contraindications: Potas~um dlloridt ~ {oolfllindiulr<1 in palients with hyptrb itmia, chronic mloIl fi ikJll', s)'Itern ic oKidosis, !M'It dehydration, extl'nsm lissue b~.kdown is in II"I'fIl' burns. acill'nal insufficiency. or tilt
administration of a pol.ssium-spoilring diurttic.
INTERACTIONS
Dru;rDrug: Potas~um IU~lI imfl"iKlwi1h potaslilm-~1I9 dln!icli and
440
UnII4
pH" 7.3&-7.45
Nonnal plasma
Ammooium dlIoride
Sodium chloride
w~h pota&5ium
oN....
Ac id os is
Al ka los is
CNS depression
CNS stirrulation
Convulsions
C~.
Imbalances
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441
Alk.alosl~
SrW'r~ diarrbta
Kidllf'/ faikJr~
Ili.Jbtte mdlilUi
w e , akohol ingetion
Srm~ vomitiog
Starloltioo
~ Prototype Drug
Sodium Bicarbonate
ADVERSE EFFECTS
ADMINISTRATION ALERTS
Do nOl.dd oral pl!'piration 10 cakum-mntaining wiulions.
GiW' oral sodium bic.rbonate 210 3 hoots bmre or .Iter mNls and ot~r
medications.
P~n.J ncyCill~ory(
MOSI
Contraindi cations: P.titnu who art ~om iting or haW' conlinllOUS Gllooioniog
will iose acid and chloride.J nd may bt in a ,tat~ of metabolic .Ikalosis;tlitrriore,
tlM-y lhoold not R'{~W' lOdium bicarbon.lt. 8K.JUII' of tire sodium contemof
this drug. it lhoold be USN Qlutiou~y in patienu with cardiacdiINlI' and renal
impaitmerll Sodumbicarbon.te il comraindiutfd in patienu with hyptrt~n
sion, peplic ukfr~ dianfrt.J, or vomiting.
INTERACTIONS
Druq-Drug: >ocilll! babonift maydfmalt tM.bIorplion of~and
may IiKll'Urininalion of duuoamphetim, rp/Ifm~, p\rooofplu..tiM, and
quinKW.T~ rilli!lilmnof~ium, ~kyI;l~ and le1raqdm rnay ~ OONW
L1 b11511:Urilaryand lfIum pH mIMe with sodUn bO:boniI:f mnistrilion.
llIin.ry 1I'000iOOlji'l1iffl11rnay OONIf.
HfIba lIFood: Chronic l1li' with nilt or calcium suwk'mmu may GlU'if llill;--aka~
~,.rond~iJndl.naHilfd Iryseriwl ~JlffUkfIW and possibIf Ioidnty
PHARMACOKINETICS
f.jkl~.
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stimulation occur including nervousness, hyperactive refl~s , and convulsions. In metabolic alkalosis, slow, shallow breathing indicates that the body is attempting to
compensate by retainin g acid and lowering internal pH.
Life-threatening dysrhythmia s are the most serious adverse effects of alkalosis.
44 2
monium chloride are two drugs that can quickly lower the
pH in patients with severe alkalosis.
Aph~ian ordm digoxin (l.noxin) 1.25 mg. but mt. mto writt O. m. Tilt
nudent nurll' gim digoxin 1.25 mg. Who is ~iblel Tilt ph~ian?Tht
prim"., nUIII'?The nursing inlll\l(\oll TIlt nurse m.nager?
SIt J{IptndIxOAlrlhtIlJgqmM<IlSWeI".
There is a continuous exchange of fluids across mem branes separating the intracellular and extracellular
fluid compartments. Large mole;;ules and those that are
ionized are less able to cross membranes.
31.2
313
31A
31 .5
Bectrolytes are charged inorganic molecules that areesSl'ntial to nerve conduction, membrane permeability,
water balance, and other critical body functions. Imbal ances may lead to Sl'rious abnormalities.
31.6
Sodium is essential to maintaining osmolality, water bal ance, and acid--base balanCt'. Hypematremia may be corrected with hypotonic N fluids or diuretics, and
hyponatremia may be treated with infusions of sodium
chloride. Dilutional hyponatremia is treated with diml'lics.
31.7
31.8
31.9
Which of the following mechanisms is the most important regulator of fluid intakel
1. Thirst
2. Ele.;;trolytes
3. Renin-angiotensin
4. Kidneys
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Which of the following nursing interventions is most im portant when caring for a patient re;;eiving a plasma vol Wlle expander!
I. ARiess the patient for deep vein thrombosis.
2.0bserveforsignsoffluidoverload
3. Encourage fluid intake.
4. Monitor arter~ll blood gases.
CJllfllfr Jt
Hypernat remi~
2. Hypen:alcemia
J_ Hypoglycemia
4. Hyperkalemia
Dl5orde.-s
443
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EXPl DRE
~-.------,
M-,flJrslnglOlls yos ooe SlOp for online chapter ~.... malerials aoo
feSOllr(;llii-. Prll!lilfe 1o. &UCCQ55 with additional tJO.ex-'-5Iy1u plattice
QuestkJ1s, InleradNe RSSIgnmenlS and activities, v.-eflilnu, Mlrmtlons
and ~kIeos , anti flICIei
RegIster lOOr IICCI'!9$ eooe from the rlMI d vour IlMk lit
www.mynlA'silgidleom.
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UN ITS
The Immune
ystem
CHAPTER 3l
CHAPTER 33
CHAPTER 34
CHAPTER 35
CHAPTER 36
CHAPTER 37
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DRUGS AT A GLANCE
LEARNING OUTCOMES
IMMUNOSTIMULANTS
Interferons
paJt450
pajt451
p4)}
IMMUNOSUPPRESSANTS {)451
Anti bodies plJl}t.f58
Ant imetabolitE's arK! Cytotoxic Agef1ts n&
Cakinetlrin Inhibitors
poqtfSV
,.,..w
KEY TERMS
ct.
plasma
{Q}t447
T(eU {Q}t4S0
Klieimmunity fklIIt449
nriboclies pt1J(441
ntigen fXl}t # J
imlllUlO1lJPPltSsant pt:I}t451
tiW {XJgt449
~tft"felOO
Bul
fXTJf"'
biologic ~ponsemodifltl'l
calcinwrin n457
piXJtf51
~tHlf1Ikin {Q}t.fJj
tran~lant
~~atiOillill1munil.tion {Q}t448
pa!.Siw imllIunity
cytokint 17451
humo~1 imlllUnt'
1fJ1lt45J
mponse pt1I}tUl
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~tU9
r!jtction fkXjt.fJl
~cilt {XJgt44B
therapy that affects body defenses.. In ~e patients, Immun omodulators afe used to stimulate body defenses so
that microbes or Cll ncer ce lls ca n be more effectively attacked . On other OC(asions, It is desirable t o suppress body
defenses to prevent a transplanted orga n from being rejected by the Immune system. The purpose oftnts cMpter Is
to examine t he ph<lrmacotherapy of drugs t hat are used to
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and Antibodies
The htnoral illllllUlle ~spo.se is initiated when an antigen encounters a type 0( lymphocyte known as a B~. The Ktivaled B cell divides r.lpidly to form millions of copies, or
dones, of itself. Most cells in this clone art called pIima (elk
whose primary function is to sec rele litibodiesspecific to the
antigen t hat ini tiated the challenge. Circulating through the
body, ant ibodies, also known as immunoglobulins (lg),
physically interact with the antigens to neutralize or mark
them fordestruction by other cells of the immune response.
Peak produ ction of antibodies o"urs about 10 days after an
initial antigen challenge. The important functions of antibodies are illustrated in ~ Figure 32.2.
After the antigen challenge, memory B cells are formed
that will ~member the spific anligen-antibody inteTKDon. Should the body be exposed to the same antigen in the
future, the body will be able to manufacture even IUgher leYels of antibodies in a shorter period, approximately 2 to
3 da)'!i. For some antigens, such as those for measles,
mumps, o rchicken pox, mtmory may be retained for an entire lifetime. Vaccines are sometimes administered to produce these memory cells in advance of exposure to th e
antigen, so that when the body is exposed to the actual organis m it can mount a fast, effective response.
PHARMFACTS
448
UnitS
Th~
Immune SY"'-""
CEll.-MEOIATED IMMUNITY
Target. invaden outside ""II. (e.g . viru ..... Stimulate both humoral and ""II-mediated
bacteria. fungi. protist and toxins)
immunity by releasing cytokines
...... -Q ----------
viral ---~";"
antigen
~
Viral antige..
pre.ented on the
.urfa:esof
dendritic ""II" or
macrophages.
and infected cells
antibody
-! ~
' 0"
helper T cell
-t
-t
~
'\-
-1
.. .
-t
.'
-"'-;;.~'-''--:--7
Cytokines released by
helper T ",,11a .timulate B
cella and cytotClllic T cella
. ..-""
-! )( I-
"
:-t
-..oryll ...11
help..T ""II
Source: Audl>sirk, Terf'5/J;Audes/rk, Gerold; 8j{'r5, Brucl', Ufe Of) Earth, 91', 0 1010
VACCINES
Va"ines are biologic agents used to stimulate the inunune system. Vaccinations are oneofthe most important medical interventions for the prevention of serious infectious disease.
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'ho",tln
~
FIgunJ2.2
Dfug.fortmmu MSystEfn
Modul~tlon
449
binds 10 antibody
Funcnom of anllbodles
RIm,NJ.
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or
450
I
j
"
t
UnitS
example, maternal antibodies cross the placenta and provide protection for the fetus and newborn. Agents infused to
provide passive immunity include immune globulin following "xposun: lu h"l'atili~, anliv"niu" fur s"akd)il~, a",..l..,rd
used to treat botulism, tetanus, and rabies. Drugs for passive
immunity are usually administered when the patient has al ready been exposed to a virulent pathogen, or is at very high
risk to exposure, and tnere is not sufficient time 10 develop
active immunity. Patients who are immunosuppressed may
receive these agents to prevent infections. Because these
drugs do not stimulate the patient's immune system, no
memory celli; are produced, and protective effects last only
2 to J weeks. Table 32.1 lists selected immune globulin
preparations. Pharmacotherapy lJIustrated 32.1 shows the
development of immunity through vaccines or the administration of antibodies.
Most vaccines are administered with the goal of
preventing illness. Common vaccines include those used to
prevent patients from acquiring measles, influenu, diphtheria, polio, whooping cough, tetanus, and hepatitis B. Anthrax vaccine has been used to immunize people who are at
high risk for exposure to anth.rax from a potential bioterrorism incident (chapter 1200 ) . In the case of infection by
the human immunodeficiency virus ( HIV ), experimental
HIV vaccines are give n after infection has occurred for
the purpose of enhancing tne immune response, rather
tnan preventing tne disease. Unlike otner vaccines, experimental vaccines for HIV have tIlus far been unable to
prevent AIDS. Pharmacotherapy of HIV is discussed in
'napter 3600.
Vaccines are not withoul adverse effects. Common side
effects include redness and discomfort at tile site of injection, and fever, minor aches or arthralgias; and for live vaccinations, a "sub-clinical" case appearance of the disease
(e.g., minor rash with measles vaccination). Although severe reactions are uncommon, anaphylaxis is possible. Vaccinations are contraindicated for patients who have a
TABLE32 .1
Drug
~ute
(C)"toGam)
1M; 0.06 ml.J1o;g is soon 011 pos~bIt liter npolUre, prftera~y within
2( h, bI.c no I.!erlilon ] diY';repu,lt-lOdi)"l .fter "pol""
IV;I00-1oom9/mo
1M;11ml.J1o;gfollo\>i!,d byO.6ml.J1o;gMf'/ 1-4wk
H)1le!Ttt)
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Adve~
Effects
...-
' hlp"'!l
45 1
PHARMACOTHERAPY ILLUSTRATED
32.1 Mechan isms of Active and Passive Immunity
1IocMt... V..:cine
AdrririotInd mcrrthe ... ~ aft.
m.I
aCcine. booster ......,a". ........ tt..
imrrKne eystem 10 maintiwl ...augh "*""'Y
c ...... to mount a "'Pid ~ to ..,
antigen.
u..
"~ lmm"My
AdrniI'ieu'J,bOII of
vaccine or eo.poeure 10
.. ..,tigen ,timlAat..
tt.. bodv tD~
a ntiboche n
.......ory c. ...
PH ai"" immunity
Adn-miotration 01
j!TYT\lI'IogiobUilll (anlibodiM)
giVM pauive i"."unity which
hu a last onset , but lut. only
3 to e month!.
RoopooH"""
.,tibodi..
(r~
T cells rapidly form dones after they are activated or sensiliud by an encounter with thei Tspecific antigen. Unlike B
cells, howtver. T cdls do oot produce antibodies. Instead,
activated T cdls produce huge amounts of q1oline, which
art' hormone-like proteins thai regulate the intensity and
duration of the immune response and mediate ceil-to-ceU
com muniC3tion. Some q'lokines kill foreign organisms dirc.:dy.
wh~r""s
IMMUNOSTIMUlANTS
Despite attempts over /Nny decades to develop effect ive
drugs 1113.1 slimul3 te the immune system 10 fight disease,
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but Iho<1-Wwd)
m.
klciinlAla!kiIUtM~Aru.fngIOCDCllitilIic!,791i.ofIIItio! z.)UI'"
!Ill tM
452
ScheduleandAge
IM;05 mlil aqtS 2 mq 4 mo,6 RIO,ancl 15 mo;dikRn ~ 12- 14Il10 who 11m no!
btftl...oo...utd rta;" a ~ngIo: do",
Adrk\: 05 mlin thfN do~ wilh IhI' se(ond dOlI' 10 days alltr thl' mt. and !hi' final dOlI'
6Il10 after IhI' fiI'II
lIII'aIIei,mllllpl.and nmla(MMRUj
Proqwd is a (ombinalion of MId Rand varia-lia varniit's.
12- 15mo
~onddOll'al"9l'4-6)'1
poIioviru>,inaailllttd (lPQj
ltII .... irus (RoIirD:, RotaT~j
i16111O)
vakella (Varivax)
only a few such medications are available. These agents include interferons and interleukins produced by recombinant DNA technology. Inununostimulants are listed in
Table 32.3.
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C""IU, n
~ Prototype Drug
45]
ADVERSE EFFECTS
Hepatitis Bmulll' is used to provide activr immunity in indivwals who all' <II
riskforelpolUll' to hepatitis BviM(HBY).k is indilattd forinlan" bornto HBYpoIitiv~ mothe'l,~nd thOl~ <II high risk fomposull' to HBV-in~cted blood, inckiding nulVS, physici.ns, dtntist~ dtnttl hygitnists, morticians, .lnd
paramediu.8fulM HBY in~tion isutll'meiy diffiruh to tll'a~it is prudentfor
all hNlth call' wonm to 1l'Cei"l'l' HBV "I<lCci~ ~foll' btginning their clinical eduCiltion,unlts,conmindicated.The Yil(ci~ isako indiCilt~d for all ~rwM who
~~ in high-lisk tmlal practic6, wch as heterosuual activitywith mukiplt
panntn, femalt prOllitu~,or holllO\tlual or bisowl practicH or prISOns who
Il'p~atedly cont"' t \eil(Uilllytransmitt~d in~tions. HBY vacci~ does nor provide protfClion aqain \I UpolUll' 10 oth~ (non-B) hepatitis viru Ie. HBY VilCu~
is prodlK~d through ll'Combinant DNA tfihnology using )'Nst celklt is not pIl'pall'd from human blood.
Hepatitis B\\KCillillion ll'""ill'S three' 1M injtc.tions;the II'cond dole isgivrn
1 month alimhe firs~and the third doll' 6 months alimhefirst dos~.The drug
is lII'arly 100% effeai"l'l' in providing immunit-; to HBV. Theeffectivelll'u of the
VilCcilll' in prodKing immunity in adults dtdi~s with age.
The most tornmon adl'!'rse effects from HBY "I<lCcination all' pain ill the injtc.tion sit~ and mild to modtrat~ Ityer and thills.Approumall'ly 15% of piI1itnu
will experiente ')'Stemic eflecl!, usually fit9Jt,diuine~ ~~~ i nd hNcbche.
Hypersen~tivit)o ~idions such il urticaria or i lOlphylu~all' pollibllo.
Contraindi tations: This "I<lCd~ is comraindicated in patieml with h)'ptrsens~
tivit-; to )'I'all or HBY "I<lCcine. Pill~nts who demonmated \e"l'l'1l' Itjoptrsmsitiv-;1)' 'a ,.... r,,,, m.,.m' .....iIlrin. ,hnnlrl nn' rt'{.;.,. "'''''-1'''''' do"".Th. drug
should beadminismed with Cilution in patients with fever or actil'!' infections,
or thOl~ with tornpromill'd wdiopIJlmolOlry 'IiIIUS.
INTERAalONS
Drug-DIIJ!I: Unbiown
li bTesis:Untnown
Herbi VFood: Unknown
Treatmfnt of OW'rdOSf: OI'!'rdosrs hal'!' not ~rn ll'Corded.
ADMINISTRATION ALERTS
O. s.1: 2wk
Prak:6mo
Halfliff: Unknown
Duration: Sto 7Y
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TABLE32.1
Immunostimulants
Drug
Adwrse Effects
akle5latin (PtoItl.iln):lnttrltukJt.2
INTERFERONS
Q
tim~
dillrrhfG
1M (AVOMJ~ 30 mcwwt
Inaplrttui5 hf1lMrogxjdty
~ Prototype Drug
ADVERSE EFFECTS
Afkdiu syndrorlM' of fMt mills, dizzin~ss, Ind fatigue OCCUI"I n S09G or patiMts, although this lISlJoIlly dimini~hei lIS Iherapy proglesse. Htac!ache, nlusti, vomitinll dianbfa, and anOrtxill art ldilively (I)II1mon. Dfprtssion and
wicidal iOtation h.'o't bHn ftPOrttdandmay bt stYt,ul"ICUgh to It'quift' discominuation of the drug. With pwlonged therip)', Sfrious toxicity such as imJlJJnosuppft'Ssion, hepalotoxicity, and neurotoxicity may be obsered.
(ontraindications: Cofttraindiutions indudt hypti"Itnsitivity tI inttrftrons,
iIIIoimJlJJIlt !lfpatitis, and hepatic der:omptllS<ltion. Neollitti and infants
Ihould not m:tM!!hil drug becalM it contains benzyl alcohol,Ydlich iI associated with an inutased incidtllD! of neurolo9ic ilnd other S4!riouI (omplications
in mtS4! agegroups..
ADMINISTRATION ALERTS
Thf drug illoold be administertd under 1M tlft'ful guidalKt of a IlNhh
Cirt Prll'Iider uperifficm with ill 1M.
SubclllanfOUS admininu.tion is ~omrnendfd for patieflu il rilli; for
b~ing (plartlet count lesllhan SO,OOOimmJj
P~nancy c.all'gory (
PHARMACOKINETICS
tnset Unknown
Pe.U-12h (IMJ
Half.J if~:2h
Duriition:Unknown
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INTERACTIONS
(hopltlll
45 5
Assessment
(Continued)
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4 56
UnitS
Th~
Immune SY"'-""
lR'at minor m~ ~lIecn symptomatically. (Mioor ~VI'M ~ffKls m.ay lit trmed
with ~mminoph~n or as ordloR'd Ir; the he~kh taR' providtrfor low-ilradt
fe\lellltss thn lOn, for localized tl'ndtml'u,orfor minor anhralgias and
malaist.Cool tornp~!eS to injer:tion .ruy help allt'/i.!tl' .rulaist, ft'/e~or
injer:tion ~te lOn'ne s.)
Aslffi thf patiem for pll"lious use ofSCG 'U(d~and (onlUk with the health
taR' providtr beim giving PPD ("Mantoux1 !kin ttsting for 18.(8(G stimulate
immunity to th~ tulltrrulosis and II'Ctnt vaccination ilia)' caUSf an ~VI'rll'
R'action to PPD injection or II'sult in a f.J lse positive R'action.)
TNCh the patient thu prt"Vioos !M ofBCG may rrsult in a falll'positiVI' 18 test.an unusualll'action to the PPO ("ManlOUl1 testor
that other teting may br R'quired to tonfirm or refutt (urrent
infer:tion.
mt
Ihtprovirler.
Pati~t
Pati~t
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Chop", ll
IMMUNOSUPPRESSANTS
Drugs used to inhibit the immune response are called
immunosuppres5ants. They are used for patients receiving
transplanted tissues or organs, and to treat severe inflammatory disorders. These agents are listed in Table 32.4.
32 .6 Immunosuppressants for
Preventing Transplant Rejection
and for Treating Inflammation
The immune response is normally viewed as a lifesaver that
protects individuals from a host of pathogens in the environment. For those receiving organ or tissue transplants,
however, the immune response is the enemy. Transplanted
organs from donors always wntain antigens that trigger the
inunune response. This response, called tril nsplilnt rejrction, is
often acute; antibodies can destroy transplanted tissue
within a few days.lbe cell-mediated branch of the intmune
system responds more slowly to the transplant, attacking it
about 2 weeks following surgery. Even if the organ survives
these challenges, chronic rejection of the transplant may occur months or even years after surgery.
Immunosuppressants are drugs gi~n to dampen the immune
response. One or more immunosuppressants are administered at the time of transplantation and are continued for
several months following surgery. In some cases, they are
continued indefmitely at low doses. Transplantation would
be impossible without the use of effective immunosuppressant drugs. In addition, these agents may be prescribed for
severe cases of rheumatoid arthritis or other inflammatory
autoimmune disease>.
Although the mechanisms of action of the immunosuppressant drugs differ,all suppress some aspect ofT-cell function. Some act nonsel.ectively by inhibiting all aspects of the
immune system. Other, newer drugs suppress only specific
aspects of the immune response. Obviously, the nonselective agents will provide more widespread immunosuppression, but carry greatH risk of adverse effects.
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Dwg.forlmmu""Sys'"", MoWlat"'"
4S7
Because the immunosuppressants are toxic to bone marrow, they are capable of producing serious adVt'rse ~ffects.
During immunosuppressant therapy, the patient will be susceptible to infection from all types of pathogens: viral, bacterial, fungal, or protowan. Infections are common and the
patient must be protected from situations for which exposure to pathogens is likely. Prophylactic therapy with antiinfectives may bewme necessary if inumme function becomes
excessivelysuppre:5Sed. Long-term survivors of transplants are
also at high risk of developing cancers, especia\ly lymphoma,
skin cancer, cervical cancer, and Kaposi's sarcoma.
Drug cbsses that have immWlosuppress~nt activity in_
clude g1ucocorticoids, antimelllbolites, antibodies, and calcineurin inhibitors. The g1ucocorticoids are potent inhibitors
of infianunation and are discussed in detail in chapters 33
and 0 00. Theyare often drugs of choice in the short-term
therapy of severe inflammation. Antimetabolites such as
sirolimus (Rapamune) and azathioprine (Imuran) inhibit
aspects of lymphocyte replication. By binding to the intracellularmessenger {.laneurin, cyclosporine (Sandimmullt, Neoral ) and tacrolimus (Prograf) disrupt T cell function. The
cakineurin inhibitors are of value in treating psoriasis, an inflammatory disorder of the skin (chapter 4SOO).
R~call from Section 32.2 tb.1t antibodies are proteins
produced by the immune system to defend against microbes. In fact, Section 32.3 discussed how infusion of antibodies can provide passive immunity. It may seem
puzzling, then, to learn that certain antibodies maybe administered to patients to suppres5 the inunune response.
How is this possible?
When animals such as mice are injected with human T
cells or T-cell protein receptors, the animal recognizes
thesf as foreign and produces antibodies against them.
\'/hen purified and injected into humans, these mouse antibodies will attack T cells (or T-cell receptors). fuur of
thesf antibodies are used as immunosuppressants. For example, muromonab-CD3 (Orthoclone OKT3) is administered to prevent rejection of kidney, heart, and liver
transplants, and to deplete the bone marrow of T cells
pr ior to marrow transplant. Basiliximab (Simulect) and
daclizumab (Zenapax) are given to prevent acute re.i ection
of kidney transplants. Infliximab (Remicade) is used to
suppress the severe inflammation that often accompanies
auto immune disorders such as Crohn's disease and
rheumatoid arthritis. Note that the suffix ~ab in the
generic name refers to antibody. Because some drugs in
this monoclonal antibody class are used as antineoplastics,
the 5tudent should refer to chapter 3700.
4sa
ThelmmuneS~em
UnItS
TABU: 32.4
Immunosuppressants
"""
Adverse Effects
ba~lilimab (SjmulKt)
~izumib (ZeNp.xl
iIlIDimab (RemiGldt)
ANnBOOIES
illikillfll (KiImt)
wtlioprint (ImUlin)
cydopho5Jlhamidt (Cytox.ln)
(S!:f ~ 556 for tile Prototypr
..,,,.00,
NmI~
maHH 9:
l(lmrill!JMJIt.I'i:I
l()(dllmiMftll~tir#{pI1I,.,t/)fMm4
HMd4d1t.gIoJsiris,"IiriJ,miId~/ltJMf/
[)ugbox OO )
((!:IICtpt.Myfortic)
iWlill1U! (R.Ipal1lll1~)
antmla throntboM2I!:nla
'""""'"'
/lypetfpidemia
HvprnrnSM IN*Q!!tria WEii !bmmlmtl"dl!'!lja
~~K'tooclarv
trmsillllimus {ToriseI)
nt...mns Ill!lljg~OO'
alli~m. inftQioll!
dj'iUV gr mA Jronn
intmtilial l!!!!l
bjrtl! drfem
tlraldomldt (Thilomid)
"""'...
Iwjr
prripMr,! ntUropathr
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,..,
Adverse Effects
1hItism,1ImIOt Nniting
CALCINEURIN INHIBITORS
QIdosporinto ~'I.~ncinltrune)
H'!'Dt!!~
MI
nrphrolOm~J
Im!rrt.!ltmia
~_,~M,~IItodJdt(
De"'"
!!!f!!!it
~ Prototype Drug
hypmtrmnit
is len toxic 10 bone rnlflOW <tis. Whtn p!e(00ed for Iw.splint It(ipients, k is
of a gkJaKorOCoid lOCh oft pINMoIII'. (~ is apprlIfd fa! t~ prophr\.ilis of kicInfy. hNre. MId 1M.
tfWplanl~: psoriisis; 1M JCt,ophth.lmil,ln ~ condition 0( diminisNd ttar pIOCbtion UIMd t.,. ow!.. inft.mllWlion.An IV loon is miWbR for
traIISplant~ ,md for~ morsel uftr"ift{oIimorCrohn's dismf.
ADMINISTRATION ALERTS
Ntoral {rniuof,rookion}...d SandilllllUM' iI~ 001 biorqllinlmt omd tillI001 be IMd inwdiangrillll, wilhool: ckM supervision bJth~ health tiI~
ADVERSE EFFECTS
The primary ~ ~Ifm olQ'!bsporin~ Q((OO in the kid~ with UplO 7'fn.
of pil!itml ~lIptfimcing rtduction in urine autpUI. INtr hill" thf patitnu !akinog
tilt drug will ~Cf hyptrtension ilnd tmMr.Othtr <OmmOn ~f i!fft<ts
_ hudiJdle,ginginl hype!plasil,ilndmillfd Mj)itK ~.AIthougIr 0,portllninic: inftiono; oc:rur dUM9 (y(mporioJe thrra~ thry iI~ ff'ftr thin
with IOII1f of tM ocher immunosuPPffSSilnts. Periodic: blood (ounts irf IW'ISill)' to msu~ thIt WBU do not f4l1 below 4,000, or pIat~~ below 75,000.
lDng--tmn tlJeqpJ inrm~ tM mI: of miligniJrq,~ lymphomas illII
stiIIUl'(tJ'S.
Conlni ndiutiom: The only ronIr.Iinlic:, tion aprior hypmeMitiority totht drug.
.......
ON}-Drug: ~lhadfaN'it~lewIi~p/IfrrfUiII,
Pregnillq m~ory (
INTERACTIONS
PHARMACOKINETICS
On~:7-14days
IIeIbIVFogd: ~juKe{iJnr.liw~IrwIs"'~2OJIi.1M1hj
hak: l-4h
Half.life: 16-27 h
Dur~lion: Unknown
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UnitS Thl'lmmun<>Sysll'm
Assessment
Impleme"tation
intervenlionsand (Rationales)
Tram tilt pititnt to rrport ~ny ftRr OY!'r 101' [II' ~I instructed by tilt
health Wt providtr.
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(Conrtnuedl
Instruct the patien! 011 the nffii 10 rHUm fl!quently for folow~p WI
~h,or trMlOl10rilt.uiill.
....
,...;.dJ
immullOlUpp~sioo.)
The patiellt.fam~ 01 (ilrtgivtr should be ablt to S!iIIt the If. SOII fat
tht dill!}: ilpplDpNte dolt and sdltduinj:wlwt idw~ rifu to
oIMrw forand ~ 10 If port ;.nd the anoop.ltfd Imgth of
rntcIic.tion thnapy.
mlllMt the tflti'lefll'Ss ofdrug thttapy by (I)nfirming tila! patRm gcNls and 9pttd outCOIMS h.1't bttII inti (set "laMing").
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r tf Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within each chapter. If any of these points are not clear, refer to the numbered section within the chapter for rt'view.
cluding interferons and interleukins, that boost the pa tient's immtulesystem. Theyare used to treat certain virnl
infections., illUllUnodeficiencies., and specific cancers.
boosting 3J\tibody production and producing active im munity. Passi"e immunity is obtained through the admin istration of antibodies.
dfk T cells and thesecrdion of cytokinessuch as interferons and interleukins that enhance tht' inlmune response
and rid the body of the foreign agent.
32.5 Inununostinlulants are biologic response modifiers., in -
A 55-rear-old female patient is receiving cyclosporine {Neoral, SandimmWlt'} aftt'r a heart transplant. The patient
exhibits a whitt' blood cell count of 12,000 cells.lmml, a sore
throat, fatigue, and a low-grade fever. The nurse suspects:
I. transplan t rejection.
2. heart failure.
3. dehydration.
4. infection.
Which of the following statements by a patient taking cydosporine (Neora!, Sandinunune) would indicate the
need for more teaching by the nurse!
I. "I will report anyreduction in urine OUtpU1to my
physician."
2. "I will W<ISh myhands frequt'ntly."
3. "I will take my blood. pressure at home every day."
4. "I will lake mycyd"-'porineat breakf""t wilh a g1ass of
grapefruit jui,e."
The nurse should monitor a transplantpatit'nt forthe ma jor adverse effect of cydosporine (Neoral, SandimmWle)
Ih .. raryhy ".,.,.""ing which lah 1....1'
I. CBC
2. Serum creatinine
3. liVl'T enzymes
4. Electrolytes
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3. Infection
4. LiVl'T disease
S. Metastatic cancer
II
Tht' type of immunity achieved through tht' administra tion of a vacant' is called:
I. active immunity.
2. passive inununity.
3. titer.
4. vaccint'.
A 5-year-old child is due for prekindergarten immuniza tiollS.After interviewing ht'r mother, which of the following responses may indicate a possible contraindication
for giving this preschooler a live vaccine (e.g., MMR) at
this visit and would require further exploration by the
n"...,,1
I. Her oousin has the
nU.
'ho", .. n
463
2. A patient has been exposed 10 hepatitis A and has been reft'Tred for an injection of gamma globulin. The patient is
hesitant to get a "shot" and says that h is immune system is
fUll'. How should the nurse respond~
1. A patient had a renal transplant 6 months ago and is taking cydosporine (Neoral, Sandimmune) daily. Identify
three precautions that the nurse should be aware of when
caring for this patient.
EXPLORE
M~rsi1~lIit
~.-----,
is )'001 COl! stop lor
resource~ Pfepar~
CJI'Ijtne
www.mynlllMlGkltcom .
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DRUGS AT A GLANCE
LEARNING OUTCOMES
Glucocortkoids (Corticosteroids)
{XIJt470
Q prWnlJor/f! pagt411
ANTIPYRETICS pl1lJt41l
Q ocelamlnophen (1)"lenot olhfrs) {!OI}t471
S. Compare and contrast the actions and adverse effects of the different
nonsteroidal anti-inflammatory drugs (NSAIDs).
KEY TERMS
ilnaph-,laxis {8/t4(f,
antipyretic fklIi~m
Cushinljssyndrome M , 47I
tydooxygeniSf (COX) PI1fJl461
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histamine plljt4M
inflammation jllHjt4M
mast (ell f!II9t465
prostaglandins plljt461
salicylatt pl(}t468
salicylism {llq 468
'lIopl,,1l
~r
465
PHARMFACTS
enced. Although there is discomfort from such scrapes, inflammation is a normal and expected part of our body's
defense against injury. For some diseases, however, inflammation can rage out of control,producing severe pain,fever,
INflAMMATION
Inflammation is a nonspecific defense system of the body.
Through the process of inflammation, a large number of
potentially damaging chemicals and microorganisms may
he
nelllr~li7oo_
TABLE 33. 1
Inflammatory Disorders
Anhritis, th!' most (ammon infiamm'tory disotdtr, is tilt lNtIing tilUS!' of
disability in tht United SUil's.
InA,mm'tory bowt l disust ,fftIU JOO,OOOto SOO,OOO Amtriuns
uth~ar.
Mediator
Description
B"dykinil
Pft'stnt in ,n illiClM form in pinna ,nd mut (elts; v,rodilator that tilu:;tS p.lin; t/fttts art simit" to tho!t of hiltamint
CorrpItmtnt
Se-its of ,t Ita\! 2(1 prottins that {OOI~III' in a U5tldt f"hion to nM"lU! Of dtstroy ,n 'ntigtn
Hiltamint
Sicftdand rfiustd by mall (tlts;uu:;tS rilation ofblood I'tIstI5, smooth-1flISdt (OIIIIriaion, t~\Ut sWl'iting. alditdJing
lMotrients
~di1l
Pretnt in most USwtl "Ill !Iortt1 ,00 ft'lmtd b)' m"t (tls;inuu~ upilla'l ptmIubitity,anroKl whitr blood (fils to silt of ilft,mmation"OO
YII~p.lil
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466
UnitS ThelmmuneSystMl
.- hiItarrine
b...tykifin
M. . ""
. . .alrienu
Sli....IIII""'oI
"""""endings
(pain)
33 .3 General Strategies
for Treating Inflammation
Because inflammation is a nonspecific proo;ess and may be
caused bysuch a vari ety of etiologie$, it may occur in virtu ally any ti~ue or organ system. When treating inflammation, the following general prindpJe$ ap ply:
Inflammation is not a disease, but a symptom of an
underlying disorder. Whenever possible, the (IIUse of the
inflammation should be identified and treated.
Inflanunation is a nlltural process for ridding the body
of antigens, and it is usually self-limiting. For mild
symptoms, nonpharmacologic treatments such as ice
packs and rest should be used whenever applicable.
Topical drugs should be used when applicable because
they cause fewer adverse effects. inflammation ofth~
skin and mucous m~mbr.mes of the mouth, nose ,
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'lIopl,,1l
NONSTEROIDAL ANTI-INflAMMATORY
DRUGS
Nonsteroidal anti-inflammatory drugs ( NSAIDs) such as
aspirin and ibuprofen have analgesic, antipyretic, and antiinflammatory properties. They are widely prescribed for
mild to moderate inflammation. Doses for these agents are
listed in Table 33.2.
with NSAIDs
Because of their relatively high safety margin and availability as over-the-counter (OTC) drugs, the NSAIDs are drugs
of choice for the treatment of mild to moderate inflammation. The NSAID class includes some of the most frequently
TABLE 33 2
On"
467
Adverse Effects
SlOOIh pWfl.NQrmum 1XI6I'I!,
MlIIb'~rmiM,~bIfflmg
,~
initilvlailb,lItmo!yti(illl'mii, !!ms
syndrom~ in dlldll'n
mtlabolkiddosis
SELECTIVE COX-2INHIBI1OR
~oxibICfl~)
DiorrMQ,ritlptl'fio,~
phQryrrs, fIIl/r
No Kfiouudyct\C ~ffrm.byt
. ,"",
.dillurisal
u,noprWn INaIton)
~O;300-600 mg Ud-
ftlrliiprofm (Ansaid)
irmmtllladn IndcKil)
utoprofm
melcJxicjm(Mobk)
nabumtlone
ox.JpnIli1(Diypro)
pi"o:Iic.Jmlfddtolll')
toIme~n (TotKlin)
.""",
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Arachidonic acid
I
NSAIDs block here
CycIooxyg&nasa-1
(COX-I)
CycIooxygenase-2
(COX2)
Prostaglandins
Thrornboxanes
Prostaglandins
inhibilors block
hm.
I
Gastropro19ction
(Decreased acid
production;
incroa.sed mucus
production)
Incmasad platelet
aggregation
Renal pro19ction
Vasodilation
Bronchodilation
S&Ioctiva COX-I
Inflammation
Pain
""",
Decreased platetet
a9l1egalion
SALICYlATES
Aspirin belongs to the chemical family known as the
sa licylat~~ Since the discovery of salicylates in 1828, aspirin
has become one of the most highly used drugs in the world.
Aspirin binds to both COX-I and COX-2 enzymes, changing
their structures and preventing them from forming inflammatory prostaglandins. This inhibition of cyclooxygenase is
particularly prolonged in platelets, where a single dose of
aspirin may cause total inhibition for the entire 8- to 11day life span of a platelet. Because it is readily available, inexpensive, and effective, aspirin is often a drug of choice
for treating mild inflammation. Aspirin also has a protective effect on the cardiovascular system and is taken daily
in small doses by millions of people to prevent abno rmal
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clot formation and strokes. The fundamental pharmacology and a drug prototype for aspirin were presented in
chapter 1800.
Unfortunately, the large doses of aspirin that are needed
to suppress severe inflammation may result in a high incidence of adverse effects, especially on the digestive system.
By increasing gastric acid secretion and irritating the stomach lining, aspirin may cause epigastric pain, heartburn, and
even bleeding due to ulceration. Some aspirin formulatiofl'l
are buffered or given an enteric coating to minimize adverse
GI effects. In some patients, however, even small doses may
cause GI bleeding. Because aspirin also has a potent antiplatelet effect, the potential for bleeding must be carefully
monitored. High doses may produce sil licylism, II syndrome
that includes symptoms such as tinnitus (ringing in the
ears), dizziness, headache, and excessive sweating.
469
..
Cydooxygena5e-l
cydooxygena~-2
"""
Functions
th~ blail
M~iat tl
I Ibuprofen (AdVli,Motrm,others)
PHARMACOKINETICS
Onset:11>-60 min
~k: 1-lh
Halflife: 2-4 h
Duration: 4-6 h
INTERACTIONS
Drug-Drug:8Kaw ~en (OIn alfen pIotelftflMion,iIs Ull'shcUd bf.rroidi>d
wIIfn !akilllj anticoagWnts and oth@rc<glllationmodfirrs. AsPrinlM lin
dMMe 1M iIII~-inn.nmatOl)' iCtion ofibuprofPII. lbul"ftrl mayillClNIf pIiIsIIIiI
IMIs of lithium,<aU~ng lithium toxirity.llII' iCtionI of certain diumics IIIiI)' bf
dimin~hN wIIfn taken COllCU1P11t1y with ~1'Il1Jst with other NlAlls,akohol,
or (OIOCO'imoidllllil)' utI\t ll'lious aml'lll' Gl_1S.
liI bTests: lbuprofm IIIiI)' ilKll'a\f blK>cing tine, aspanatr tranliminaSl' (AST), and
aLin-.e transamillR (.IJ.TIIMIs.lt IIIiI)' ilKrNlf hemoglobin and lIrma!ooit.
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UnitS Thl'lmmu""Syst""'
ACtioos(0h,lOOS).
5erI"alll"lKlYniIms are beIiMd to aaront for t.r am~inflammatory aajy
ity of EPA and DIIA. The two rompetitiYely inhibit !hi' (OI1'Imion of arac:hidoni:
ac:i:l to tilt proilAamfNlory prostagbndm, tie reducing tlltir synthtsis.
Intrrac:tions may O(Qlr btIWffn fish oil ~pplrments and aspirin and otht r
NSAIDs. Ahhoogh rarr,mh intrrac:tions might be rrunifuttd by in(reasrd
~tibility 10 bruising. nostblfflk. hemoptysis, herruturia, i nd blood in tht
,,00[
GlUCOCORTICOIDS (CORTICOSTEROIDS)
Glucocorticoids have numerous therapeutic applications.
One of their mmt "..,f,,1 pmperti"" is the ~hililyto s"rp ...... s
TABLE 33 4
Dru,
PO;O.6- 71mg1day
...""-~-
bOi ool
1IIIlhir9. ~ irrwmtio,5IIdirJmrDi
IIlJid rmntiln, impoirFd \IOO/ld MdRj,
'""""'-
PO;OlHmgbid~id
Q prtdnisonr
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Adverse Effects
MoJ~ wtighl9CI~ ~UIt, (odol
PfQ~{ vlar
hypoY){fOlja (p\IfO!IOfO'ij!
mmdegfiltdQ!9W1h il dlildrm
Do!~ble malljoo o!'ilkoiOO!
~ Prototype Drug
47 1
I Prednisone
absm!t1.
Do oot III!' if signs of a ,~tl'lllic: inftion a~ prerm.
Whrollliog thedrug forlllOll'thao 10days,tlltdol!'mtIII btllowly taprred.
PlI'9nJIK)'(.iltgory(
ADVERSE EFFECTS
Wht n ulrd for soon-1Mn thrraP'l. prNoisone hu few W'riou! adww tfifru.
Long-1Mn therapy may reuh io Culhiog's I)'Od~ a (oOOition that in(kidts
h)1ltllll~fmia, lat redistribution to thr shouklrl\ ,00 facr, musclr 'Maklll'n,
bruising, JMbone that Nsily frxtu~. Offiul(' gastric UktB may occur with
Iong-1Mn thrrapy,an aODuker mrdic:ation may br PIl'ICribtd prophybctiully.
lkrwith uution in j)atirnu with peptic: ukf~uktliltivr (olitis,or diYl'flirulitis.
Contraindi u lions: Patiffitl with actiYl' yjra~ b"teria~ fuoga ~ or protOlOan iofections lliould oot take prednilOlil'.
INTERACTiONS
Drug-Drug:8Kaw barbitwilfl,~ iIOd ~n inmu jIIfOOisoM
mNaboM,incJNlfd~may 1M> ~IM {roamnt u'" with oIIIIpboIHicin SOf
diurMiG ilKlNl@';~ ~ which maybe I!'riouI fOf pMnlllAilg!igm:in.
OOIM prNlisoIII' yn raj", blood gluco!f t....eI!, diabetic pMnts may ~l ill
~u'illllPnt in 1lll'doIfSofminorOfillh~fmic .... ts.
l.i b1151s:I'Iedni!ooI> may inhibit iIltibody n!lpilI"6f to tollid! lIOd YiCone; lIOd
may ioof6l' blood ~ ~ Ykium,polllSiim,lIOd th)llo..... may dKJI'U.
PHARMACOKINETICS
Onset:Unlrnowo
~k: 1-lh
Halllife:1Sh
Duration: 24-36 h
FEVER
Like inflammation, fever is a natural defense mechanism for
neut,.,.lizinS foreign ors~nistru; . M~ny . pecies ofb~cteria are
killed by high fever. Often, the health care provider must detennine whether the fever needs to be dealt with aggressively
or allowed to run its course. Drugs used to treat fever are
called antipyretics.
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high fever can break down body tissues, reduce mental ~cu
ity, and lead to deliriwn or coma, particularly alllong elderly
patients. In rare instances, an elevated booy temperature
maybe fatal.
The goal of antipyretic therapy is to lower body temperature while treating the underlying cause of the fever, usually
an infection. Aspirin, ibuprofen, and acetaminophen are
safe, inexpensive, and effective drugs for reducing fever.
Many of these antipyretics are marketed for different age
groups, including special, flavored brands for infants and
children. For fast delivery and effectiveness, drugs may
come in various forms including gels, caplets, entericcooted tablets, and suspensions. Aspirin and acetaminophen
are also available as suppositories. The antipyretics come in
various dosages and concentrations, including extra
strength.
Although most tevers are caused by inlectious processes,
drugs themselves may be the cause. When the etiology of
fever cannot be diagnosed, the nurse should consider drugs
as a possible source. In many cases, withdrawal of the agent
causing the drug-induced fever will quickly return body
temperature to nonnal. In rare cases, drug-induced fever
may be lethal. It is important for the nurse to recognize
drugs that are most likely to cause drug-induced fever, including those in the following list:
Anti-jn!eajws: Anti-infectives, especially those derived
from microorganisms such as amphotericin B or
penicillin G, may be seen as fore~n by the booy and
472
UnitS Ttelmmu""Sysll'm
HOME
&
COMMUNITY CONSIDERATIONS
Th~ Question:
ADVERSE EFFEaS
Aretrminophen is 9fnt rally liff,and admt efletu alt' unrorrmoo at therapMic: dosr-s. Atttaminophen caUlfl 1l'1l CJilstric irrit.Jlion tha nalpinn, i nd does
nol affecl blood (I)igulation. k is not It'oommt ndtd in patients who ill' malnourished.ln SIKh lilts, iant IOxicil)' may I!"IUIt.ItadillCj to It'n.r1 fa iult', whic:h
Lln ~ fatal. Other signs of aartt toxKit)' inc:ludt naUIN, wmi:ing. chills, abdomirwl disoomfort,and fatal hepatic: nKrosis.
Amajor 00nc:1'III with tilt 1M of high doses of etaminopllt, is III! risk for
Ii-It! dama9f. Til! drug has caUlfd livtr failure in a numbfr of patients, whic:h
hasll'luhed in tilt FDA issuing wamillCjs rt'9arding tht 1M of thr drug. Tilt risk
is signific:.JmI, glt'atr r in patifnu who(oosumt akohol.
ADMINISTRATION ALERT
INTERACTIONS
I)ug-l)ug: A(flamioophen in~lJin Williann flll'taboism, UIIIiI9 thf
antK~ to ilmuoola!, to tOD: IfwIs. HiljJHlos.! or Iongurm oIa:Mlli"lophtn
hY~lII'IIsitivit~ 10
ttamino-
mug with
Lab Tl51s: AMillninoph!O lOa)' iKruse llfpiltir: Iunaion Ill! "laUe! IIlh iSl!'IIIO
bilirWin, aIp.arIiI' iIIIImtr.lnsli>ru tAST), and aIanifMo amilouansffliM (.I.lJ ).It
II"Ia, irKrNIeoollillY ~.JlydroxyiHlGeoK!tir:Mid (5IIMl aooll'flll1!ric: Mid.
HfrballFoo:l: fINo paliI'fl! WUd i'llid takilg hl'fbs that II.wf thf poIt.ltii11 for li'IH
(oltsfoot, and (haparTai.
PHARMACOKINETICS
Trt'iItment of ()ytrdo~: Tht spt<ifit Ill'iItment for O'/trdol!' is Ite ora Ior IV ad-
ministration of H-amykysteiOl' (h:mdotr) as soon as possibltafttr the OYI'rdost. This drug pro1l1tU tilt Ii-It!irom 1Oxic: mttabolitflof iKetallinopiltn.
Half~i~:Hh
Duration:1-3h
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473
Assessment
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474
Unit; ThelmmuneSyu,-""
CominUl'to monitor ptriodic: lab work: hepatic: and ft'nal furKlion teu, (Se.
eleo:trolytts,glurost, lipid le<iels. and roagulalion studies or biffiling Iimi'.
(Aspirin and "liql.1O< .!ftct platelfl.9'I"9"ion .nd ,hould br monilOrtd if
used Iong-trrm or if ml'SSiYt biffiling or bruising is ooltd.Armminophen tan
br hepalotoxit. CortKl>lteroids a!fed tht (SC,and i widr range of electrolyre,
gkKose.)
Monitor for ilbdomiOiI pain,blac:k or larry stools, blood in lhe 11001, htotalel1ll'Sis
or roffn-ground etnM, diuifltlS,and hypottooon,~iaOy if assorialtd with
loKhytaldia.(NSAIOsand giutocortic:oids may (luse GI bleeding.)
0
0
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0
0
',,"plOI
475
InsUUl:ltht patient to wtigh Itlf diily, idully at tilt limt time of~.
Tht patient should Jtpon signifK.lnt weight gain or ill(rt.sing
ptriplltral edtm .
noti!)' the htakh UIl' provider ilunable to t1kt medication for mOl!
than 1d.1y due to illnes~
Iong
-.-,---I-.-:T~:::::h::;:tllt patient to not !lop liking glucOlrticoidl.bruptly and to
Tht patien~ family,or [iftgi ...... should be i1b1e to statt the INson for
tilt drug; appropri.rtt dolt dnd Ilheduling;whdl advtM t fTall 10
obit ...... for and when to rtpOI'~and thtanticipated Itngth of
mtd~ion tht"p)'.
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476
UnitS Thl'lmmuneSyu,-""
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
H. l Inflammation is a natural, nonspecific body defense that
limits the spread of invading microorganisms or injury.
Acute inflammation occurs owr several days, whereas
chronic inflammation may continue for months or years.
H.2 Chemicals, pathogens, and physical trauma cause the release of chemical mediators that trigger the inflammatory
response. Histamine is one of the kry chemical mediators
in inflammation. Release of histamine produces vasodilation, allowi ng capillaries to become leaky, thus causing
tissue swelling.
H.) Inflammation may be treated with nonpharmacologic and
pharmacologic therapies. When possible, topical drugs are
used because they produce fewer adverse effects than oral
or parenteral drugs. The two primary drug classes used for
inflammation are the NSAIDs and glucocorticoids.
The patient has been taking aspirin for several days for
h.,~o.la~h~ . Duriu)o: th., a,.".";s,,,.,ut,
uur,., o.li,w.~" th.,
p.1tient is experiencing ringing in the ears and dizziness.
What is the most appropriate action by the nurse!
1. Question tbe patient about history of sinus infections.
2. Determine if the patient has mixed the aspirin with
other medications.
3. leU the patient not to take any more aspirin
4. leU the patient to taketheaspirin with food or milk.
tI,.,
The nurse is admitting a patient with rht'Umatoid arthri tis. The patient has been taking glucocorticoids for an ex -
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lure of I0 1"1'. She51ates tbe child is abo complaining oibeing tired and ac~ aU OYl"f. The mother asks how much
upirin she an giwr her daughle!" foc her temperature..
How should the nurse respond?
Su Appendix D !oranJIWn Imd rationales for Q/lacllvirits.
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EXPlDflE
~- - - - - - ,
~Kills
.-alftls l'Id
IIIIJI"
AeQISI~r 'PI'
DRUGS AT A GLANCE
LEARNING OUTCOMES
P{NI(llUNS
fA1iIt4!4
(EPHAlOSPORINS pq411S
Q ufotQKtne (Claforon)
m RAacuNES
~f!tj
ptJtW
Plgt4i19
""
AMINOGIYCOSIOES tllgH89
Q gefllllmldn (Gllramydn, omm) JUlI'491
ftUOROQUINOlOHES paJtf91
CO) dprofloxacJn (Cpo) f>7!t~j
SUlFOHAMIDES
(XlJt491
Q llfmelhopl1m- sulfamerhacllzolf>
(Boc fl1m. ~Ira) pogt494
ANnruBERCULARDRUGS
4. Using III spectflc example, explain how resistance can develop to an antIinfective drug.
MACROLIDES
IlIIJtf99
KEY TERMS
~qu irtd
ft;stan<e pogt481
bnIadspertnm u tibioti(
fWJt48}
padlogrl Nm
pathogenicity ptXJt419
Pflicilli n-bilding p!O(rin pogt484
.m!bi< paJt479
(uiturrandM'nlitirily tC&S)t~ n g
nat. Pqt}
iltibiotil: /XIgtJ
mijnftin P9Jl419
Iwclt'riocidoll j1JgtJ
N<ttriostMic {'A1gt46J
mtillions ptXJt481
luberdrs N4W
be1a-lactilll ri ng ~484
beta-laclin1st/ptnicillm- fO}tf84
_row-lpKtrumardliotic: pq4l!1
inknCf JX1IJl419
LibraryPirate
JX1IJl48)
plasmid f!lJ741!1
~ostfiOfa pq-I8J
red-rnu syidromr
~'oUiYrI)HI {XJl}tm
~ nfrcticMI PU;lW
100000nU~frctiom
pq481
fWJt499
II
in the air, water, food, and soil,mic robes are an essential component of life on the planet. In some cases, such as with microorganisms in the colon, microbes playa benefidal role in
human health. When in an unnatural environment or when
present in unusually high numbers, however, microorgan-
PHARMFACTS
Bacterial Infections
loftious di.N ~ are tilt mill! mon mmman cau~of dtath io tilt
United State!, J nd first in tht world.
food.boml' iIIoess i'll'lJlOnsiblf for 76,000,000 iIIomes; 300,000
oo~taliutiom;and 5,000 dtJtM th ym
Urinarylrl<l iof1ioo. (ur,,) Ill' th. 1110<1 mmman iokctioo I<quill'd in
oo.pitak,and nNrIy all aft' u\OCilt~ with tilt i~rtion of a urio,ry
Ciltlieter.
MOIl' thao 1 millioo oo.ocomiill iofffiiom all' aluired NCh year. These
ioftdiom add 1 day for UTII, 7to 8 days for lUr<jiCiIl ~Il' iofec.tiolll, and 6
to 30 days for pntUmanii.
Up to J])Il(, of all S.pneummiot frond in \OI1IUIN. of the Uoitfd Statn
aft' resistant to ptnicillio.
Nearly all IUJins ofS. Ql!1l'UI in the Uoitfd Stain all' resist.1lI to
penicillio.
About 71,000 ca\6ofE.mi poisoniog aft' replntd anowl~ in tilt Unittd
Statts, with the mon common .ource ~ng ground~.
LibraryPirate
479
34.3 Classification
of Anti-Infective Drugs
Antiinfective is a general term that applies to any drug that
is effective against pathogens. In its broadest sense, an
480
UnitS Thl'lmmuneSyu"",
DI5ease(sl
[)(>5C~ptlon
BlKillusiWlrlKiJ
Alllhw
Borrri~ bagOOrft~
Lym~ disu~
(h/omydio rnxhom~rif
&htridlio a:I
IIotIOOflli/IIf
KlfllJieiIo
PnellllOllia,Un
Myrobterom /fproe
Lepro!Y
.'"
Myroburom rubfrruli1>il
Tubft"rulo~s
M)ropIoS/ll~
PIIfIIIlOIlia
IilintriD gonorrl1oeve
IiliJifflo mmingiridJ
Menil91i1 il dlildrffi
I'MuI11lXlli
PrortrlS mirobilil
Un ~ inftctions
l'lerJdomoooslltflJgiOOJ~
RkkPwi~ ricterrJii
~lmoMloffirtriridS
Food poisoring
5rap/ly/OCM (ljrtUs
5rfllplococCU5
....
anti-infective drug may be used to treat bacterial, fungal, viral, or parasitic infections. The most frequent
term used to describe an anti-infective drug is antibiotic. Technically, antibiotic refers to a natural substance
produced by bacteria that can kill other bacteria. In
clinical practice, howevtr, the terms antibacterial, antiinfective, antimicrobial, and antibiotic are often used
interchangeably.
\Vith more than 300 anti-infective drugs available, it is
helpful to group these drugs into classes that have similar
properties. Two means of grouping are widely used: chemica! classes and pharmacologic classes.
Chemical class names such as aminoglycosides, fluoroquinolones, and sulfonamides refer to the fundamental
chemical structure of the anti-infectives. Anti-infectives
belonging to the same che'mical class usually share similar
antibacte'rial properties and adverse effects. Although
chemical names are often long and difficult to pronounce,
placing drugs into chemical classes will assist the student
in mentally organizing these drugs into distinct therapeutic groups.
Pharmacologic classes are used to group anti-infectives
by the'ir mechanism of ([etian . Examples include cell wall inhibitors, protein synthesis inhibitors, folic acid inhibitors,
LibraryPirate
481
RNA synthssis
i'lhibit"..:
Rifampi'l
P",tein synthesis
i'lhibit"..:
A'Tlinoglycoside&
Ollo.ampheoic:ol
Oindamycin
Li>ezclid
Macrolides
S:reptogf8mins
Tetracyclines
inhObitof8:
Cs rbopen ......
Cephalo&pori ....
I""...... zid
PIInicilins
V.n~
t
t
mR~
DNA oynthuis
-----'It--I inhibitof8:
m
. '''"".''''~
~m::::::_~SCo::
,~,~."
LibraryPirate
482
UnitS Thl'lmmu""Syst""'
1.loI8d:ion
, I Anlibiotic I
34.6 Selection of an
Effective Antibiotic
2. Anbbiotic kills all organis .....
,. FlgureJ4.2
In most cases, antibiotics are given when there is clear evidence of bacterial infection. Some patients, however, receive antibiotics to prevent an infection, a practice called
prophylactic use, or chemoprophylaxis. Examples of patients
who might receive prophylactic antibiotics include those
who have a suppressed immune system, those who have experienced deep pWlcture wounds such as from dog bites, or
those who have prosthetic heart valves and are about to have
medical or dental procedures.
Acquired resistance
LibraryPirate
In most cases, antibacterial therapy is best conducted using a single drug. Combining two antibiotics may actually
decrease each drug's efficacy, a phenomenon known as
mTfagonism. If incorrect combinations are prescribed, the
use of multiple antibiotics also has the potential to promote
resistance. Multidrug therapy is warranted, however, if seveTal different organisms are causing the patient's infection
or if the infection is 00 severe that therapy must be started
before laboratory tests have been completed. Multidrug
therapy is clearly warranted in the treatment of tuberculosis
or in patients infected with HIY.
One common adverse effect of anti -infective therapy is the
appearance of secondary infections, known as superinftions,
'hop1fll4
LibraryPirate
Drug,fo<Sx!e,latlnf<'Ctlo",
483
ANTIBACTERIAL AGENTS
Antibacterial agents are derived from a large number of
chemical classes. Although drugs within a class have similarities in their mechanisms and spectrum of activity, each
is slightly different, and learning the differences and therapeutic applications among antibacterial agents can be
challenging. Basic nursing assessments and interventions
TREATING THE DIVERSE PATIENT
make it rooItr.
48 4
UnitS Thl'lmmuneSyu"",
Penicillins
Although not the first anti-infecthe discovered, penicillin
was the first mass-produced antibiotic. Isobted from Ihe
fungus Penicillium in 1941, the drug quickly became a miracle product by preven ting thousands of deaths from infections. The penicillins are listed in Table 34.2.
34.8 Pharmacotherapy
with Penicillins
Penicillins kill bacteria by disrupting their cell walls. Many
bacterial cell walls contain a substance called penicillin binding
prattin that serves as a receptor for penicillin. Upon binding,
penicillin weakens the cell wall and allows water to enter,
thus killing the organism. Human cells do not contain cell
walls; therefore, the actions of the penicillins are specific to
bacterial cells. Gram-positive bacteria are the most commonlyaffected by the penicillins, including streptococci and
staphylococci. Penicillins are indicated for the treatmem of
!ABLE 34 21 Penicillins
Route and Adult DoSf' (max dose whj>ffl Indicated)
Drug
Advflrse EffKIS
NATURAL PENICILLINS
pmicil~n GbtnzathiM (Bidlli1)
.towsi/ltSS
prnidlin Gsodiumlpot.mium
PENICILUNASERESISTANT
doudlin (Cloxaprn)
didoxadlin
nakilin
oxadllil
BROAD-SPECTRUM (AMINOPENICILLlNS)
(Augmm:in)
ampidlin (Prindpm)
baYlI"pidl~n
PO;400-8OO mg bid
(Sprctrobid)
EXTENOEOSPECTRUM {ANTIPSEUOOMONALJ
PO;381-764 mg qid
pi~roKilin sodum
pi~roKilin wob.Klam
(Zosyn)
ticardlin (rKa')
LibraryPirate
IV;B75gqidOW'rlOmin
1M;1- 1 g qid (max:14g1da,)
'hop1fll4 Drug,/o<Sx!e.lalllll<'Ctlo",
o
II
485
/S,/CH,
J.
C - C- NH - CH - CH
\\//H.
II
C - N-
O~
C,
I CH,
CH - COOH
Il-La.dam ring
- ,
o
II
/S,/CH,
!.
C - C -NH - CH - HC
\\IIH.
II
O= C
N-
C,
I CH,
CH - COOH
OH
Cephalosporins
Isolated shortly after the pt'nicillins, the cephalosporins
constitute the largest antibiotic class. The cephalosporins
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34.9 Pharmacotherapy
with Cephalosporins
The primary therapeutic use of the cephalosporins is for
gram -negative infections and for patients who cannot tolerate the less expensive penicillins. More than 20
cephalosporins are available, all having similar sowtding
names that can challenge t'Ven the best memory. Selection of
a specific cephalosporin is first based on the sensitivity of
the pathogen, and secondly on possible adverse effects.
Doses for the cephalosporins are listed in Table 34. 3.
Like the penicillins, many cephalosporins contain a betaI~cl~m
~cliv_
486
UnitS TtelmmuOI'S)"tl'm
I Penicillin G Sodium/Potassium
"t
ADVERSE EFFECTS
Simi!.r 10 penic:ilin V, penicillin Gis <I drug of dioe <lgaimt strt'ptoc:O(c~ pnwmoc:oai"nd na~hyIooxci Of'9iInisms thai do 001 produu ptnic:illinm ind art'
shown to lit su lC!ptibie by (&5ttlling. k is also a medication of choiu for gonorrllta and S)'phiil UUIN by Wl<tpliblt mains. Pmic:illin Gis milablt <II~
llltr a potmilm or SGdilm ~It; llltrt' is no difirrt'n(f llitraptutiully betwem
lilt two wits.
Only 15-10%0f an oral d= of penic:illin Gis ablOlbed. ~US!' of its low
oralabsorption,prnic:min Gis often givtn by lh! IV or 1M roottl. Penic:illin Vand
amoxic:illin art' m:lR' stablt in ,tid and art' UIfd wlltn or,1I ptnic:illin thtrapy is
desirt'd. Prnic:illinas!-prodlKing orglnisms inacti'ffit both ptnicillin G and
penicillin V. Prnic:ilin Gberu:alhilll' (8ic:illin) and ptnicillin Gprouilll' (Wytillin)
Art' Io~ OCIing pl ...."""1 <.Ok< oftht drug.
PrniciUin GhiS ffW Ifflous adYerst effects. OianbN,nlUS!'a, an~ vomiting art'
tiMo most (ammon adYene tfl"ecu ind tan (aUS!' smous oompli:atiom in {hildlt'll ind oldtr idum. Pain it tht injrnion ~te miy oc:cur, ,nd !lIptrinrectiom
art' poI5iblt.Anaphylnis ~ tilt most W'rious ,dvtrSt tffect.
Contrai nd italions: The only contraindiution is ~nsitjyity to a drug in tht
ptnic:illin daIS. 8eo:.JUS!' penic:illin Gis er<reted flIensivtly by tile kidn~, tht
drug should lit UIfd with caution in ~tients with W"/ert' .... al ~~.
ADMINISTRATION ALERTS
INTERACTIONS
Lab Ttsts: Pl'ltidlil Gmay ij"lt poIitiu (rombs' tfII and Ial!.! positiVI! .linary or
W'l 00I prOieilll.
Afttr ~ .... telill administration, oblffi'l' for tm~bIt alltrgic rt'actions for
30 minut6,tspffially following tilt fim dost.
00 oot mix ptnic:illin ind aminogly(osoo in tiMo wme inlla_om soIulion. GiV!' IV n:edicatiom 1hour a~n to prt'~nt inter.Jnions.
Prt'gnalKY ~ry 8
RtI'tr III MyMIsIrtgR fur a MnJnq I'rortl! Foot! spKlIIi: 111M <tug.
Ik<rbaVFood: Urtnown
PHARMACOKINETICS
Il1wtRapid
~ak: 30-60 min PO; 1S- lO min 1M
Half~ift: 10-60 min
Ouralion: .~h
I Cefotaxlme (Claforan)
ADVERSE EFFECTS
(tWtaumt is a ttird"9flll'ration (~alosporin with i broad sptclnJm of activit"; 'gainst gram-negati~ olljanisms. k is tfftniV!' 19ainst many bitlt'rial
Speo:~slhat hiV!' df"/tloped rt'Sistanu to farl~r generation ctpha~rim <I nd
10 othtr tLmfl Ii anti-infectim. (tfotaIimt txhibits bamrioc:idal inivity t.,r
inhibiting (tll-WllIs)'lllhtsis. k is prt'S(ribed for W'riom inftions of tilt lowtr
respiratory UiKI. (fnllal ntrYOUS S)'Stffll, genitourinary sysltm, bonts. <lnd
joints. k ilia)' also lit UIfd for blood infKtionssum as bittf ll'lll ia or Sfptic:t mia .
lil:e many otht r {fphalosporilll, trfotn illll' is not alnorbed from tilt GI tract
and must IItgiven by tilt 1M or IV IOUte.
For most pat~nts, {ffotuillll' ind tht othtr {tpha~rim art' wft medilations. H~nsitivir; ~ tilt IMn (ammon ad~ tffl,ikbough S)'mptorm
ma, indlllk only, minor rilh and iUhing. Anaphylam ~ poIlbit. Glff!'trd
Iidt ffirm YKh as dianhei, I'Omiting. and nauIN may O(rur.Sane patienu fIptritlKt mmidmblt pain at t~ injtdion ~te.
Contrai nd ications:The only comraindication is hy~nsitjyity 10 a drug in the
tepha Iosporin das ~ ~USt (tWtaume is U(rt'ted ertt nsivtly by tht kidntyl,
t~drug Ihould lit UIN with uution in ~t~nu with Sfftll' rt'N1disNst.
INTERACTIONS
ADMINISTRATION ALERTS
sunounding tMutI.
Prt'gnalKY ~ry 8
PHARMACOKINETICS
J)ug- J)ug: l'robenKid UI.I\O'! dmNlrd relIal flimination of {efolaxiR and may
rtIUt io {tphalo:lporin toxi:itJ Akohol iltflam with {ffotallime to proiKe a
dsulfwam-il:e rYllion. Cefolaxime iuratn with HSoIJDllo (ikl\f an i (INIf in
platrlet inhibiticn
Lab Ttsts: Livfr fIMion test yakIfs may ~ iKrused; may give a poIitft (rombs'
test ind Ib eIevationI of W'l 00I or Irinary Ufainiw lewis.
Ik<rbaVFood:lJnI;nown
~ak: Unkno\\ll
Half~ift: 1 h
Duration: Unknown
LibraryPirate
TABLE34.3 I Cephalosporins
Route and Adult Dose (max dose where loo lcall'd)
",,"
487
Advel"5e Effects
FIRST-GENERATION
madroxil (Duric:~
aphaluil (Ktfttx)
,phOOi!ll' ('kW()
[JQrriIN,QImmilaluanpng. ~ (olii'll,
"d
SECOND-GENERATION
mador (CtdOl)
(tfolmn (CtfOtln)
a'foxilil (Mdoxin)
a'Iprozil (Ctflil)
THIRO-GENERATKlN
a'ldinr (Omnktf)
a'ItiIDml (Speara(tf)
a'fuimt (Suprax)
~(Cefobid)
Q (tfOtlxime (Clafonn)
a'IpDdoxint (vantil)
rntiZidim~
(ForuI, b1ir:d)
rntibulm (Ctdax)
rntiMximt(Ctfizox)
rntriaxo!ll'(Rocrphio)
FOURTH-GENERATlOtl
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Tetracyclines
The first tetracyclines were extracted from Streptomyces soil
microorganisms in 1948. The five tetracyclines are effective
,
~
48 8
UnitS
Th~
Immune SY"'-""
TABLE i4 41 T"tracyclinti!s
Drug
demtdoqdint(Dtdomym)
doxyqdinr (Vbramym,OII1rrs)
tigrqdint(Ty~)
34.10 Pharmacotherapy
with Tetracyclines
Tetracyclines act by inhibiting bacterial protein synthesis. By
binding to th~ bacterial ribosome, which differs in structure
from a human ribosome, the tetracyclines slow microbial
growth and exert a bacteriostatic effect. AU tetracyclines
have the same spectrwn of activity and exhibit similar adverse effects. Doxycycline (Vibramycin, others) and minocy-
Prototype Drug
IIlmiri"9. 0bd0mlM/(Jllmpi"9./linlmrt,
Jitr
Adverse Effects
PHARMACOKINETICS
1l1'51't: 1- 2 h
Peak:2-4 h
Half~ifd-12h
Duration: 12 h
LibraryPirate
ADVERSE EFFECTS
kiog i broad-spKIrum antibiotic:. tttracyclilll' M i tt ndeocy to affKt vagillill,
oral, and intlstinal flora and caU\e wPf(infe<tions. Temcydine irrifates !he GI
II"IKOU and may ColU\e niUIN, romitiog, tpiljistric: bum iog, and dia niIe.J. DiarrhN may lIt~R' tllOll9h !OUUst discontinuatioo 01 thrrapy.Olhrr common
side effKls in(1ude discoloration 01 thr tffih and pOOt<MnsitiYity.
Contraindications: Tetracydinr ~ (ontraindimed in patients with hypmtnsitili!)' 10 drugs in th~ eLm. Thr drug should not lit used during tht \fcond half
of prrgnaocy, in childrt n8 )'I'ars or yoongr~ indio jItients with 1f'IM' Il'oal or
hrjltic: impairlMnt.
INTERACTIONS
1Wg- 1Wg: Mil; jroIiKII.ion ~B, ~lIIKOIIlilining liIiIIi"ll'S,aod
antadd:! IftIlKf lht abIorplioo and If IOOIIMis of letriqd~ ~raqdilt ~1Id!
with the 1~.Jowfring mtgI (olestipoi and (OOItsiyrallliof, 1Mfir,' dKlNIing lhf
antitiolil:\ iblorplion.Th~o-lMJ dro~lhtffIK~ oforal romKtptim.
lab 115ls: May inlrfR the ~klMng Iab~~ UrN nitrogfo 18lMjJ,
aIpaftiIlf MIlinOlranlfmlf lAST), ........... aminOlrilllll'trillf wn, MIl)'W. biin.tlin,
and alaint p/IoIpIIaliIIf.
JIiorbaVhod: OdiIy ~ts irltrfmo with lfUilJdlll' ablorplion.
lINIment of Omdose: Thfre ~ 110 sprcifK trutmeot for OYl'rdo5I'.
1Itl(er.!:l MytmbliJKtl'or~ MnlniJl'rIKtsIi FooII'ipt(/It 1rI1M.:tug.
tetracyclines SllOUld not be taken with milk or iron supplements. Calcium and iron can decrease the drug's absorption
by as much as 50%. Direct exposure to sunlight can result in
severe photosensitivity during therapy. Unless suffering
from a life-threatening infection, patients younger than 8
y""'" of ~g" ~r" nol given t"tr~cyclin... b"c~us" th""" druB"
may cause permanent yellow-brown dis<:oloration of the
permanent teeth in young children. Tetracydines also affect
fetal bone growth and teeth dewlopment and are pregnancy
category D agents; therefore, they should be avoided during
pregnancy. Because of the drugs' broad spectrum, the risk
for superinfection is relatively high and the nurse should be
observant for signs of a secondary infection. When administered parente.rally or in high doses, certain tetracyclines
can cause hepatotoxicity, especially in patients with preexisting liver disease. Because outdated tetracycline maydeteriorate and become nephrotoxic, WUlSed prescriptions
should be discarded promptly.
The newest of the tetracydines is tigecydine (Tygacil), approved in 2005. Tigecydine is indicated for drug-resistant
intra-abdominal infections and complicated skin and skinstructure infect ions, especially those caused by MRSA. Nausea and vomiting may be severe with this drug. Tigecycline
is available by IV infusion.
See Nursing Process Focus: Patients Receiving Antibacterial Therapy on page 496 for the Nursing Process applied to
all antibacteria ls.
Macrolides
Erythromycin (E-mycin, Erythrocin), the first macrolide
antibiotic, was isolated from Streptvmyces in a soil sample in
1952. Macrolides are considered safe alternatives to penicillin, although. they are drugs of choice for relath'ely few
infections.
34.11 Pharmacotherapy
with Macrolides
The macrolides inhibit protein synthesis by binding to the
bacterial ribosome. At low doses, this inhibition produces a
bacteriostatic effect. At higher doses, and in susceptible
species, macrolides may be oocteriocidal. Macrolides are effective against most gram-positive bacteria and many gramnegative species. Common indications include tht'
treatment of whooping cough, Legionnaires' disease, and
infections by streptococcus, H. influenZ<l, and Mycoplasma
pneumoniar. Drugs in this class are used against bactt'ria re-
TABLE 34.S
Mr. Johnson is admitt~d for. snM' up~r ~r.tory inftion and dehydr.tion.D.Jring tilt nurs~'s initi.l ~\esml'n~ Mr. Johnson isqu~tiontd about a~
Itrgits and Il'poru being alltrgic to ~.ruts, ',pirin, sulfa, "Id ragMtd.
Followinq a history .J nd physiu Iexa mination,tht primary ca~ physician oroft"!
trimethoprim-sulfaml'thomolt (Ba<lrim) DS. Whm tilt medication alljye
from tJ\e phUJllaq, it is in a unit-dose padygt.1t is.J IaI1jl' tabltt (ontaining
160mg oftrimethoprimand 800 mgofsuKamethoxarole.TIIf' IIJI"W' bruk! t!le
tablet in halt for ~~ier sw.JBowing.and gim Mr.JohnlOn his first!losr with a
Ia I1jI' gla IS of water. What should tht nursr haYe don~ diflerrmly?
5to'Apptllll/lOfllllhtJUl}9t'imiamm:
siding inside host cells, such as Listeria, Chlamydia, Neisseria, and Legionella. Clarithromycin is one of several antibiotics used to treat peptic ulcer disease, due to its activity
against H. pylori (chapter 4(00 ). The macrolides are listed
in Tablt' 34.5.
The newer macrolides are synthesized from erythromycin. Although their spectrums of activity are similar, these
drugs have longer half-lives and cause less gastric irritation
than erythromycin. Forexample, azithromycin (Zithromax,
Z-Pak ) has such an extt'flded half-life that it is administered
for only 5 days, ratherthan the 10 days required for most antibiotics. The shorter duration of therapy is thought to inCft'ase patient adherence.
The macrolides exhibit few serious advt't"Se etfecl5. Mild GI
upset, diarrhea, and abdominal pain are the most frequent
adverst' etfects. Because macrolides are broad-spectrum
agents,superinfections may occur. Like most of the older antibiotics, macrolide-resistant strains are becoming more
common. Other than prior allergic reactions to macrolides,
there are no contra indications to therapy.
See Nursing Process Focus: Patients Receiving Antibacterial Therapyon page 496 for the Nursing Process applied to
all antibacterials.
Aminoglycosides
The first aminoglycoside, streptomycin, was named after
Streptomyces griseus, the soil organism from which it was
isolated in 1942. Although. more toxic than otht'r antibiotic
classes, aminoglycosides have important therapeutic applications for the treatment of aerobic gram-negatiw bactt'ria,
mycobacteria, and some protowans. The aminoglycosides
are listed in Table 34.6.
Macrolides
"n"
azithrom,m (1ittromal,Z-Pak)
darithromydn 16i.11il)
diitl"romym (Dynab.K)
ft)'Ibrorny<in (Hotydn, Erythrodn)
PO;500mglday
PO;M-SOOmgbidor m mgtid
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489
490
..
Prototype Drug
PHARMACOKINETICS
1l1~t: I h
Peak:Hh
Half~iM: 15- 2 h
Duralion:Unknown
ADVERSE EFFECTS
TIiI' molt frtqUtnt adYersr rflem from tr)1hromyr:in ~Il' n~UIN, ~bdominJ I
cramping,and vomiting,<lhhoogh t~ are rJreiy ~rious mough to wadisrominunion of tlil'rapy. COIKurll'llt administration with food rtdtns thI'st
l)'IIlpioms. TIM- molt ~Il' aMM dfd is htpatoioJicity c.Jutd bythe estolall' sak (lloIo ne) of tlil' drug. Hearing Iosl, venigo,and diuilll'Sl may be 9ptritncrd whl'n using high doles, particularly in older addIS and in thoJol' with
impaired hI'p;rtir: or r~naI 9aetion.
Contraindications: Erythromyr:in is rontraindiuted in patienu with hyptnen~til'ity to drugs in the macrolide dill,and fort"-taking terferudine,.ntemizoIe,or cisapridt.
INTERACTIONS
i)ug- i)ug: Ane\llwticJ,azolro oifltifu~Mld oiflticonwnll may "lfr.I(tto YIIII'
l'fllll druij Ifvm 0( erytIvOOlycinto 1M and rfIW " tolDdtJ. Tb~ Ihg n mcll
with qcIosporine, incrMilg tht risk for .000xicit~ It may iraNSI' iIIf !ffecll 0(
wilifann.Thr(l)fl()Jfffl\ UJoI' 0( fl)'thJOnin with Iov.!ruiin or~in ~ not
f!(0IIlIIfIICIfd becaIIIo! ~ may OONIoI' tht risk 01 mid! toIicity.Ethanol U\oI' may
dtoaUlol' tht abIorptioo 0( erythrorny<in.
Lab Te ts: Er)1hrom~ IIIa'f "tmlnwithAST ...-.:t gi"ll' fal\ol'urilar1c.1I~nt
.m
iJr ove~.
TABLE 14
61 Aminoglycosides
Drug
Adverw Effects
amibdn lAmikinJ
gmUnici1 (Garamycin,OIhm)
unamycin (Kanlln)
neom)\in
piIItIfIIOII1ycin(Huma~n)
!Ill'p1omycin
tobr~mycin (NebcinJ
with Aminoglycosides
Aminoglycosides are bacteriocidal and act by inhibiting
bacterial protein synthesis. They are normally reserved for
serious systemic infections caused by aerobic gram -negative
organisms, including those caused by E. coli, Serratia, Proteus, Klebsiella, and Pseudomonas. They are sometimes ad ministered concurrently with a penicillin, cephalosporin, or
vancomycin for treatment of enterococcal infections. When
used for systemic bacterial infections, aminoglycosides are
given parenterally because they are poorly absorbed from
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the Gl tract. They are occasionally given orally for their local effect on the GI tract to sterilize the bowel prior to in testinal su rgery. Neomycin is available for topical infections
of the skin, eyes, and ears. Paromomycin (Humatin) is
given ora lly for the treatment of parasitic infections. Once
widely used, streptomycin is now usually restricted to the
treatment of tuberculosis because of the emergence of a
large number of strains resistant to the antibiotic. The
nun;e should note the differences in spelling of some
druSS_uch as -mycin ven;us -micin- which reflect the
different organisms from which the drugs were originally
isolated.
491
PHARMACOKINETICS
Onset:Rapid
ADVERSE EFFECTS
Ruh, nausra, vomiting. and fatigue 'R' the most frfll~nt adY!'~ effKls. As
with . r aminog~((IsidH, <Main idft~ ~rts mlly ~ !fn~.OtotOllici\)'
<lin prod", loss of hNfing 01" b.I:oIK. , which may bt<orn. pMn.nrm with
continued 1M. Tinnilu!, vertigo, an d penistent he.td.Jchri are rally ~igns of ototoxirit)o. Nephrotoxirit)o is of partirul.tr <on{ern to patinlts with p~~Jining kid~ imj)llinnnl~ and may limit phumac:o~r.py. Signs of mi"'M kid~
iull(tion incUde oliguria, proteinuria, ,nd rlt\\lted BUN .nd <rutininr boeIs.
Rtsisull(e to genu micin is incR'i ling. and some (IOU ft'Sisull(e <lmong .. minoglycolidts has ~n II'portM.
Contraindimions: Genumicin is contraindic.itM in patients with hypel\ells~
tNit)' to drugs in ~ iminogl)':o:s.ide <taSI. Drug the"Pl' must ~ monitorM
<af"ully in palitnts with impaiR'<i renal fUnction, or thOl!' with ~.uisting
lI!>aring loll.
INTERACTIONS
Drug-Drug: 1M rill; of otot(l[idty ilKlNlfl ffthf patientis<ll"rI'Iltlytaki19
iIIIttootHidn B, fwlllMlidf, alpirin, blirnmnide, ethauynic iOd, rilplatin, 01
panrnolll)'<i1. Croamnt U!f with iIIIphotHidn B, <.Jp-fOIII)'{in, <ilplatin, ~)"IIl)"Iin
B, 01 '/olIIComy<i1 inoUlfl ~ riIII of nephrotm:idty.
liI b11'Sts: Gfntamil:in may inmasl' value! of ~ folowilg: IoffiIm biirubin, IfIIIIII
~k: t-lh
uMiniM, IfllllllIacLltI' deII)'IIrogfna;r nD!), BUN, AS1; 01 All: may dKr&N valutol
Half-life: 3.... h
Duration: 8- I 2 h
The clinical applications of the aminoglycosides are limited by their potential to cause serious adwrse effects. The
degret' and types of potential toxicity are similar for all
drugs in this class. Of greatest concern are their effects on
the inner ear and the kidneys. Damage to the inner ear, or
ototoxicity, is recognized by hearing impairment, dizziness,
loss of balance, persistent headache, and ringing in the ears.
Because perma nent deafness may occur, aminoglycosides
are usually discontinued when symptoms of hearing impairment first appear. Aminoglycoside nephrotoxicity may
be severe, affecting up to 26% of patients receiving these antibiotics. Nephrotoxicity is recognized by abnormal urinary
function tests, such as elevated senun creatinine or BUN.
Nephrotoxicity is usually reversible.
See Nursing Process Focus: Patients Receiving Antibacterial Therapy on page 496 for the Nursing Process applied to
all antibacteria ls.
Fluoroquinolones
Ruoroquinolones were once reserved only for UTIs because
of their toxicity. Development of safer drugs in this class began in the late 1980s and has continued to the pre:rent day.
Newer fluoroquinolones have a broad spectrwn of activity
and are used for a variety of infections. The fluoroquinolones are listed in Table 34. 7.
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492
TABLE i4 71 FluoroquinolonlO!s
Drug
AdVl'l'seEffecb
dnoxadn (G~{j
/iQU5lll,dia~
naidixic:uid (NtgGrim)
FIRST GENERATION
M1IIIiring, rash,hrodht,
n!S11tl~pi!in ~lIdinfl<lmmQrionor~"
SECOND GENERATION
Q dproftwdn(("pro)
norIIoxicin (NorOlin)
oIIoJOOn (Aoxin)
THIRD GENERATION
Ievolloxidn (L"iquin)
OrOP' (0.196 ophO,.h";" ""luliun);Cko dd,.. 141<1 2, .. ," d"", in NoJ, .rr... tod.,.
emf 21l0ii'i;011 doI)'i 3- 7, one !top in urn iflwtd~ up to fool time/diy
PO;25O-S00 mgfdoly [mal: 750 III9Id,,)
FOURTH GENERATION
gmlifloXidn (Firti'le)
moxifIoLJdn (AI'rIox)
Sulfonamides
Sulfonamides are older drugs that have been prescribed for
a variety of infections over the past 70 years. Although their
use has declined, sulfonamides are still useful in treating
susceptible UTis. The sulfonamides are listed in Table 34.B.
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34.14 Pharmacotherapy
with Sulfonamides
The discovery of the sulfonamides in the 1930s heralded a
new era in the treatmentof infectious disease. With their wide
spectrum of activity against both gram-positive and gramnegative bacteria, the sulfonamides significantly reduced
mortality from susceptible microbes and earned their discovert'!' a Nobt'l Prize in Medicine. Sulfonamides are bacteriostatic and active against a broad spec1nun of microorganisms.
Sulfonamides suppress bacterial growth by inhibiting the
synthesis offolic acid, or folate. These drugs are sometimes
merred to as folic acid inhibitors. In human physiology, folic
acid is a B-complex vitamin that is essential during periods
of rapid growth, especially during childhood and pregnancy. Bactt'ria also require this substance during periods of
rapid cell division and growth.
Although initially very effective, sE'Veral factors led to a significant decline in the use of sulfonamides. Tht'ir widespread
availability for over 60 years resulted in a substantial numbt'r
of resistant strains. The discoVt'ry of the penicillins,
cephalosporins, and macrolides gave physicians larger
choices of safer agents. Approval of the combination :tntibiotic sulfamethoxazole--trimethoprim (Bactrim, Septra,
TMP-SMZ) marked a resurgence in the use of sulfonamides
in treating UTis. In communities with high resistance rates,
however, TMP-SMZ is no longen drug of first choice, unless
C&S testing determines it to be thE- most effective drug forthe
specific pathogen. Sulfonamides are also prescribed for the
treatment of Plleumocysris carin;; pnewnonia and 6higella
infections of the small bowel. Sulfasalazine (Azulfidine) is a
493
I ClprofloxaCIn (e/pro)
PHARMACOKINETICS
Onset:Rapid
PNk:I- 2h
Hall~~e: I --4 h
Duration: 12 h
ADVERSE EFFECTS
Gprofloucin i, ~II toierMN by most patierlll, .nd ~ious adYme ~ffe:n all'
un<omnon. NaH~d, vomiting. and dia rrbN may oc:rur in as many <I , 10%01 p.a-tiffiu. Ciprofloudn may be administtll'd with food 10 diminish <Im rie GI rIncts.l1~ patient >hoold no~ howt-W'l, taktthis drug with antacim or mineral
,upplellll'nt~ ,ill(e drug .b>orption will be diminilh~d Some Ilitien15l1'port
photolllXic:ity, headac:he, ind diuiness.The FDA hi , is5Ued <I blac:k 1m wi/ning
thai ci~ rofloucin m.y calM tendon inflammation or ruplUII'.Arty complaints of
difficulty with w.lking or pain in the fool or leg ,hould br Il'porled immttiatefy.
Contraindi u tions: (iprol\olOl(in is rontraindiulN in Ililients with hy~f'Stl\,ilivilyto drugl in the flooroquinolonedass. The drug should be discontiftutd ~
the p.Uent v:ptritnc:t l p.in or inflammation of a tendon, as II'Ildon ruplUIl'I
haYl' bttn Il'plrtN.
INTERACTIONS
DrurOrug: (rocullall m iniltr.tion with willfann may incrNlf iIIl!iroagw n
~iIIld Ii'lUk in bleNiIg. ThilO:ul may incrNlf lhfop/IyIine k>wk lS--J09ro.
Mudcb, ftmltll .. If.to. ar>d ...,/IIf. 1f dfo'........ ob5orption of dprol1.xodn.
l.i b Ti5II: GjRIIooon mIY incrrnf UUfS of ill,.IST, serum milinine. ar>d 8I.Jt.
Herba Hood: GprofkI:iKil can incrN" 'ifMllfvel! of CilffPilf: caflNlf
con~tioo IhorMI bf' rflui:ted 10 prMII ~~"ltflfl~iIIlxi@l~1JI
talhymlia.Dairy procluot15 fI' ooum-Iortififd .tintsGlO~ .... mrpticn of
ciprolloJaCil.
Treatment of OYerdole: Tberr is 00 ~ifKtll'.unenl for OY!'rdos~.
IItI'tf rc M)MJ1l1ng/IJ1 for Q NlJrl/JII) I'rrxm fjKlIHpKlIc rc Ilris drug.
"n"
1U1f.J(~midl' ((~midl',OIhers)
IUlfaduine (MiuoIUfoo)
IUlfadoxi~pyrifMIhamire
(FiIIllidar)
IUHi~(Ganlrilin)
sulfonamide with anti-inflammalory properties that is prescribed for rheumaloid arthritis and ulcerative colitis.
Sulfonamides are classified by their route of administration: systemic or topical. Systemic agents , such as sulfisoxazole (Gantrisin) and TMP-SMZ, are readily absorbed
when given orally and excreted rapidly by the kidneys.
Other sulfonamides, including sulfadiazine (Microsulfon),
are used only for lopical infections. The topical sulfonamides are not preferred drugs because many patients are
allergic to substances containing sulfur. One drug in this
class,sulfadoxine-pyrimethamine (Fansidar) has an excep-
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p/roffMmiririry, ~oIIurio
Adverw Effects
"
,,,~
~
"
,,
0
"
494
ADVERSE EFFECTS
NaulN and yomiting an' th~ most fn'lp'nl adwrSI' efferu ofTMPSMZ therap)'.
HyptrstnlitNity is rrlariYdy (ommorJ and Uiually IIIiInifflu as lIOn rllh, it(hirg.
and few. This mtdiution !hould be used caUliwliy i1 patient! with Pfl'""uilting
~ dise~ sira u)'!tliluria,oliguria,ind nonalfaikrn' h"e bfflJ fl'porttdPt,
riodic: tabor-alo ~ f\'aluation of thf blood is ulllilly peri:Jrmtd to idl'nt~ early ~ns
of agranulocytOlis or thromboqtopeniol. Dur to the po~tial for photosen\itivity,
tht patitnt !hould iYOid din'd IlIllight during thtrap)'.
Contraindi(ations: TMPSMZ isconmindic:.ittd in palitnu with hypersensitiv
ity to dllJ9S in tilt !Ulfonamidt (taIS. Patitnts with docum~mtd rnegalobbnic:
anemiol due 10 fobtt dtrKiency should not fl'Cem this drug. Prtolnut womI'n
it term ind nursing moth~rs should not tike this drug bec.iIM sulfonamide!
llUy uou the piacema and art' fan'ttd in milk and may Wile kemic:t~M.
TrimethQPrim rifcrt'i \eS pomsium eJCfl'Iion i nd is comraindilaltd in Pitients
with hyperlilemia.
INTERACTIONS
I)ug-l)ug:TMPSMl ma' fn~ncf tIltelfem of lfai n imaglUln. ThN rNjI
may ~ incJNse mfIhotfl'U1I' tolidty.By dMNsi'lll tilt hfparic metabolism of
PHARMACOKINETICS
1l1~t: 10-60 min
Pt-ak: 1-4 h
Half~ifd-12h
Duration:Unknown
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~m(Azacum)
Adve~
Effects
dWoimpbmkol
PO;lSHSOmgqid
Anan/rtIiiNI IlIprrilfraioM
r;urfw;mg
R~~m!!!Mm!iIil.!!!!!2!I!!mJ~
iUplorTI)'tin (Cubitin)
1Y;.mgi'l;goncumy 24 h for7-14dlys
tlUpI'netn (mw)
IVr1M; 1gfdaV
t2im
NeulIa,riarrfn,lIlIIdhl
~~I!!!lli!ih WllHiIf~i~m. DItIIdommll!!i!ll1!l ~~nil.
fosfomydn IMonwol)
Imlptlltm-<itastJtin IPrinwinJ
PO;SOOmgticl-"(max.:8 gilby)
NeulIf,flarrfn,lIlIIdhl
An~l!!rllald1. !UmffctiOrK
Il'..tI.Idommlbr.!1lOllS (oIi!:i1.
blood dyscmias
1V;1-2gtid
mtrOptIItI"ft (Mmml/V)
IMIllmamlnt (M.vidtLlmint,
Hiprtl,UI6)
l<ilwl:!
IMlronicLuolt (~)
Anal!!rflald!.mm1uria
PO; 7.S mglkg tm)' 6 h(max:4 g/iU,)
IV Ioaifng do~ 15 mgi'l;g
IV maintCMOO: dtJt; 7S mg/kg fmJ 6 h (1IIil: 4gfd.J)')
nitroliranloin (ftJJdintin, ~
MaoocIantin)
ltIitlram)'dn (~t.l
NeUIfII,IOOiti"9
PO; 125--500mgrvtfJ6h
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496
UnitS lhelmmulleSyslem
Assessment
Inftction
P,io Ilfl;itM to infffiionJ
Hyperthermia
MOen! Knowltdgt (drug theraP'()
Rill! for Inju!)' (Il'littd 10 Id"lflSl' drug tffws)
Rilk for Dl'lio:iellt FluidVoume (IfIattd to ieYer,diinhea (lU\fd by
adYen.~ drug tffem)
Rilk for Nonrompliall(f (Il'Iattd to adYers~ drug effects, ritlio:ieot
knowledge,or (Olt of medic:ation)
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IlIItnJct the p'tient 011 the nffif for ptriodic: lib work.
497
ContinII!' to monitor for IItparic, rena~ andlor ototoxicity.lAmibam ria k that al'l'
htpatic, rroal,orototoxic It'quil'l' flt'querlt monitoring to pl'l"lt'nt adv~1'!!' effects.
Inclt'<I ~ng Auid inta~ will plt"/emdrug ,(QJmulation in kidn~.)
Continuo to monitor for dollllillologic clkru induding ~ 0' P'Jrplish skin ,...h,
blineB, i nd sunburning.lmmrdiateiy It'pOn Itftlt' r.JIsIIes,tspKialiy mociattd
with blinering. (Tetr<lt),:line, IUif0na midts, <I nd fluoroqJiooion~ may caust
,igniflC.l nt dermatoiogic efftcts including Stt'lens- Joilnson ,yncllOlIII'.
Suf'l\{reens and protect~ (Iothing should he used for <l ntib.Kteria.k that cause
photosensitiYity.)
T~ach
<I~oid
sunburn or rashts.
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498
UnitS
Th~
Immune SY"'-""
in p.!tierru on peniciliins.(SoIllt
preparations of penicillin lIIiIy lit based in SGdium or potassium salts and rna)'
calM hypemat~mia and hyptrkaiemia.)
bt<01lll'
The p.!tien~ famii)\ or caR'g~r shook! lit abitto stare the R'i50n for
lilt drug;appropriatt clost ind sclitduling;wlw adYI'rsr ~m to
obll'n'l' for and wlltn to R'port; ,nd the amic:ip.!ted lenglh of
mttlic,tion therapy.
Evaluate lilt efff{t~IN'SI of drug therapy by (onfirming th~t patient goals and txptatd OUIrome\ hoM been mt! (see "Planning').
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TUBERCULOSIS
Tuberculosis (TS) is a highly contagious infection caused by
the organism MycoboCfcri,,,,, wbcrclliosis. The incidence is
staggering: More than 1.8 billion people, or 32% of the
world population, ue believed to be infected. It is treated
with multiph.' anti_infectives for a prolonged period. The
antitubercuJar agents are li sted in Table 34.10.
34.16 Pharmacotherapy
of Tuberculosis
Although M. tuberrniosis typically invades the lung, it may
tr"vd tu uti",. lJuUy b~(~IU'" I!arti<.ulady 00'''', via tI", lIluuU
or lymphat ic system. M. tuberculosis aCliv.ates the body's immune defenses, which attempt to isolate the pathogens by creating a wall around them. The slow-growing mycobacterj~
usually become dormant, existing inside cavities called
tubrrdn. Theymay remain dormant during an entire lifetime,
or beconK' reactivated if the patient's inunul1t' resporu;e be_
comes suppressed. Because of the immune suppression ch:lT_
aCleristic of AIDS, the incidence ofTB greatly increased from
t985to 1992;as many as 2O%0fall AIDS patienlSdevelopac_
tive tubt'rculosis infections. The overall incidence ofTS, howevl'l",hasbeendecLining in the Vnited States since t992, due to
the improved pharmacotherapyofHIV-AlDS.
Drug therapy ofTB differs from that of most other inf_
tions. MJ'Wbacteria have a cell wall that is resistant to pene_
tration by anti_infectiV(' drugs. For medications to reach the
microorganisms isola ted in the tubercles, therapy must continue for 6 to 12 months. Although the patient may not be
infectiow this t'ntire time and may have no symptoms, it is
critical that therapy continue for the entire period. Some
patients develop multidrug- resista nt infections aOO require
therapy for as long as 24 months.
A secoOO distinguishing fea ture of pharmacotherapy for
tuberculosis is that at least two. and sonletimes fouror more,
antibiotics are administered concur rently. During the 6_ 10
24-month treatment period, different combinations of
drugs may be used.. Multiple drug therapy is necessary because tht' mycobacteria grow slowly, and resistance is common. Using multiple drugs in different combinations during
the long treatment period lowers the potential for resistance
and increases therapeuti c success. Although many different
drug combinations are used, a typical regimen for patients
with no complicating factors includes the following:
SOO
Un/l~
ThelmmurwSysum
TABLE3410
Drug
Antituberculosis Drugs
Route and Adult Dose (m~~ dose wnere Indicated)
Adverse Effects
FIRST-lINE AGENTS
tlhambutol (Myambutol)
!niR!!t~lb
Q Isoniazid (tlH,Hydmid)
lit,nlTB
PO;300 mgld.y or 900 IIHJ IWKf 'IIftkIy for 6-9 mortm
.I.ctln TB
Wis ~Iri~!
p)'minamidt (PIA)
Al!illl:rdi!i11ai!9IWiW~ w.l1ImI2IlI~
hcmokdcanrml.
rifalrulin (M1lobutin)
.twU!
rifaptOti'l~ (Priftinj
(S~
.miUcin(.I.mikilJ
(~T.bI~34.61
i'ldMduaI drugs)
SECONDLINE AGENTS
dprofloudn (Gprol
~Tabl~34.n
<yclostllnt~)Idn)
{)rowrinru, 1IfGdht.1fI~'0'
tlhionamid~
(Trt(oJlorsq
~122II1ttH[11iI~IlWlMIl! ~!.2!2!!~
t!2m:1~~jgDI
pm;1:I!Im OOlil:lllll
NIlU~D, KJmiring,
,/igmrir ~ diorrlrto
bnolm)Kin (Kintrl'lj
IM;5- 75mgr1lgbid-tid
(SHlabldU)
oIIoMdn (FIoxil)
1I1!p1(1111)'cin
~-.
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'hoplfll(
SO l
I Isoniazid (INH)
ADVERSE EFFECTS
Th~
ADMINISTRATION ALERTS
PHARMACOKINETICS
Onset:lOmin
PNk: l- 1h
Halllifr:l-4h
Du.~tion: 6 8 h
mort common Idvrl!!' dfrm of isoniazid art' numbneu ofl11t hands .nd
11'fI. fiSh, Ind ~r. An FDA bIoKk boJi warning for isoniuid states tIlals~1l'
andlOlnelilDf"! latal hepatitis hill btl'n rt'pOotd with this drug. AlthoUiJ! rut,
hl'palctoxic:ity uSIYII)' OC{Ur! in Ihl' fir!t 1 to 1 monlhs 01 thmpy bu may
presl'm alaO)' tirnedurilg trWrnenl Thr nul!!' shoukJ bt alto br ~fI!ofj.Jun
dn, !.ri:)lIt, I'Imttd hepatic I'I!l)'DIf!, Of loss of appl'til~. Hrpati: et"Il)'IIIe test;
a", UlUIIy ptrbnned monlhly dJring Ihtrap)' to idrmify uri)' htpalolouar,.
Contr.indimions: Isoniazid is conmindic:,u td in patient; with hypernnsitivil)' 10 tK drug and in pllient; with Sf'I!'re IItpatic: impainnl'nt.
INTERAalONS
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,
"~
502
UnitS
Th~
Immune Sy"'-""
Assessme nt
Infenion
fatigUl'
ImbalalKrd Nutrition, lfss than Body Rtquift'rntrlil (ft'latfd to fatigUl',
ildYtnt drug dftas)
Dr/ic:imt Know\edgt (drug tlltrilp)'. inftion (ontrol mrillurH)
Risle for NOIKompiialKt (ft'latfd to ildft~ drug tll"K II. rltrKirm
knowlr<lqt, ltnqth of trNtrntnt ft'quirtd, or (ost of mfdilation)
Risle for Scx:i.lllsoiation (ft'latfd to disfalf,ltngth of tlN1ment)
""',,"
T~ ~tient will:
fxp~ritlK~ thernptUtil: tifKtS (~.g., di minisMd signs and symptoms of infection, rlr<ft'ased f~tr and fatigue, inaust<l appetit"t J.
Sr mr from, or expMtn(f minimal. arlYmr rffrru.
VfflIal~ an undermndinq of tilt druq'1 Ulf, ad\'elSr ffieru, i nd requirtd prtUutions.
~monlmte proptr IfIf-admin~tration of thr milation (f-9,dOlf, timing. wlltn to notify provider).
Impl e me ntatio n
Inte rve nti o ns a nd (Rati o na les)
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'""""-J
MonitOl" lor ~s Ind symptorm ofllfllrolr.:kity, p.lrtir:ulaitt prriphtral oIIId
optic: nNlOpm.y. (HwrotoDily oIIId periphtral nMitis.1I! .dYtMtfftS 01
.ntiluberorlosis drugs. Vrtlmin BalNy bf 0Idered 10 deut.st It.e risk of
periphelll ntUropitb): )
'alitnts u king riflmpin shook! bf (iUliontd thlt drug may tlllTllKdy IUds
(Inri, swu~ Slli'B,urirlf) lfddish~rlnqt.(Efff(\ is IIIrmitss bot mly suin 10ft,
hj'drophiil: (OIl!'" knses 01' dodringJ
Tt~ tilt patitnl to ((Insult: w~h drr tyt (ill! pllWidK btIo!t using
h)'llrophilir: (ontact 1t1lStS.Considtr wtaring nonwhillt ciodling or 1M
uodtl"9lrmtnl) if Swtilting is elltmiYf.
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50l
504
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
34.1
34.2
34J
34A
Anti-infective drugs act by affecting the target organ ism's unique structure, metabolism, or life cycle and may
be bacteriocidal or bacteriost~tic.
34.5
34.6
34.7
Host factors such as immune system status, local condi tions at the infection site, allergic reactions, age, and genetics influence the choice of antibiotic.
34,8
34.9
Superinfections are an adH'rse effect common to all antibiotic therapy. The best description of a superinfection is:
1. an initial infection so overwhelming that it requires
multiple antimicrobial ag<.'nts to treat successfully.
2. bacterial resistance that creates infections diflkult to
treat and often resistant to multiple drugs.
3. infections requiring high-dose antimicrobial therapy
with increased chance of organ toxicity.
4. the overgrowth of normal body flora or of
opportunistic organisms no longer held in check by
normal, beneficial flora.
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A patient has been prescribed tetracycline. When provid ing information regarding this drug, the nurse would be
wrrect in stating that tetracycline:
I. is classified as a narro..-spectrWll antibiotic and only
treats a few infections.
2. is used to treat a wide wriety of disease processes.
3. has been identified to be safe during pregnancy.
4. is contraindicated in cMdren younger than 8 years.
Teaching for a patient reu'iving a prescription for
ciprofloxacin (Cipro) should include (Select aU that
apply):
I. Report unwual heeL lower leg or calf pain or difficulty
walking.
2. Amid taking the medicine with milk products and
antacids.
3. Linlit vitamin C, both dietary and oral vitamin forms.
4. Take her pill with an antihistamine to avoid side effects.
A patient has been diagnosed with tuberculosis. While his
medicine is being administered, he asks questions regard -
505
GI upset.
J. A 66-year-old hospitalized patient has MRSA in a cellulitis of the lower extremity and is on gentamicin N. What is
a priority for the nurse to monitor in this patient!
EXPLORE
aQ,ll!Iitilng!tlr------,
MyMlrsil1 gl(i! is )'OIJ ! one stop lOr onI"Je ehapter reVIew mill<'!lial:! and
resou rtes. Prepilrt tor SI.OXer.s witI1 additiooal rnD:~stvle practice
Ques!loos, Imenu:t"". assignments ood actI";mes, well links, anima1ions
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LEARNING OUTCOMES
Q omphom;dn B (FungjZCJnf',o""'''i
O fluconazolf'rD/RucQn) Jll9f51J
2. Identify the types of patients who are at greatest risk for acquiring
serious fungallnfeCllons.
""",
o nynorin iM)"".ralin,Nynop,o/hfo",
P1m
Drugs p!JIJt516
Q mtlro"d/u'o"IFlQgyIJ ptJIJ(5U
ANTHELMINTIC DRUGS
po!JtSIl
Q mtb<!n~IV<!~ fllll}t52J
S.
6.
7. Use the nursing process to care for patients receiving drug therapy for
fungal, protozoan,and helminthic infections.
KEY TERMS
iIlale f'I1J' 51]
derm.rtophytit
filii}' 'jQJ
dywntery JIIlT517
frgosterol JIIlI1'5IJJ
erythro()1intigf ~ m
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fungi fIIJIJ''j()J
mytlSI'S pogtsaJ
helmimh P'11d1J
miliary pogt m
polyene fllJlJ'515
protOIOil fllJlT5r5
meU\lo~es pogt515
1Nst pogt'j()J
-.
PHARMFACT5
SYSTEMIC
BIosromyrrs dmOQrilidi.
Cilr111idoiJlliam,oihrfs
fsKddioidfs immiriJ
UyplOaKM ntOforlOQO!
(rypto{Ouosis; opporturillic; brgill in thr luogIM is thr most common cause 01 meriogilis in AIDS ~iffit!
Iinop/lllll"lQ(llpsuiarum
SUPERFICIAL
Cilr111idoiJlljrar;,oihrfs
Epidfrrooph)'fOlllloc:W!IIm
.w{~!pKie\
SporolMx I(/im(kii
Trichophyron sprOO
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507
UnitS ThelmmuneSysI""
t'I(~kmkOJ-15~infwdlMl
O .nphotman B(AbM~
"'"'
AmBI-.MIphotN,FungiIJ::Jnto)
. . . . . E_
I
TABLE 15.2
508
_1HII1~fIIOftriI.lIftJd~
.lOOIRlungili (bull)
fkK)1o~~ (Antobon)
""""'"
rhl!:mOOphltli!is
""""'"
~hNdfIt,i!~lrNrtdpllltliril!nl
!22!I2aSJiIliLIi'~iS 12!iSi!:I:
.miufingin (MJtmiM]
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rmat tlllU.
HtadXht,_,lIlIII.pNtliliJ
lMIefIii
~ I!!ml~ !.Ktions.litliri!!!!
OIoplfl n
(Abelcet, AmBisome, Amphotec, Fungiwne) and fluconazole (Diflucan) are drugs of choice. Selected systemic antifungal drugs are listed in Table 35.2.
35.4 Pharmacotherapy
of Systemic Fungal Diseases
Because human immune defenses provide a formidable barrier to fimgi, serious fWIgal infections are rarely encountered in persons with healthy body defenses. The AIDS
epidemic, however, has resulted in the frequent cli n ical occurrence of previously rare myooses, such as cryptococcosis
and coccidioidomycosis. Opportunistic flUlgal disease in
AIDS patients spurred the development of several new
509
Liposomal.mphotericin B(AmBisomt): consist; of (Iosfd sphtric.J1mi(les.Amphotericin Bin inttgrilttd imo the lipid mtmbr'n~
Amphotericin B lipid {ompl9 (Abeled): (om,ins 'mphoteric:in B (ompined with two phospholipids in, 1:1 ratio
Amphotericin B (holtstt rylsulfut (omplex (Amphotec): conl;1I> of , 001Ioidal suspenlion of amphott ricin Bin, 1:1 ratiowith the lipid c~ttryl
sulf,t~ in mic:roscopk dislc-s/l,ptd partic:1es
ADVERSE EFFECTS
Amphotericin Bun procItn fIl'qutm and somtlim~s serious oJdverno riftas.
M~1l)' patienu develop ieer ard <hilk, Omiting, ~nd he~doKhe ~t tht btginning oIthmp)', whic:h subsidt., t~mem {ontinUH.Phlebitisis oommon during IV ther'p)'.SorMdtg~of III'phrolOJirity is ~rwd in80%ofthepatitnu
IoIking this drug ,nd t\fCtroiytt imbilllnces wc:h ., hypob lemii flfqtltntly DC(ur. (.n:liac 'rrH~ h)1lOleOlion,and dysrhythmill 'Il' pos~ble. ~use ,mphotericin B(In UI/Ie ototoxicity, the nu~ should .!Isns for huring loss, erligo,
unste,dy gait, or rinnitus.
manyOOiql.(r.oonfllthfl"apy with
drll9l that r " N flllctioo, well 011 amirlogl)'(osidn. irKwny<in, or Glrbo!Utin
is oot lKomlllHldfd.l.I\.! with (ortiarswoids, Ikfletil musdf ~LlOU,.Jnd thiazd@
miIY potmti.!l~ 1l)lIOkilfmia.l!st with dilJOlin inaNSes tilt risk of digoxil toxicity in
Drug-Drug: Am~n 8 inlHiKtS with
..........
ADMINISTRATION ALERTS
Infus~ slow~, b~u!Murdiornculir(ollap~ mol)' Il'sult if the medication
is infused too rapidly.
Administer Pfl"medication to help rIKrN~ the risk of infusion ~.ctions.
Withhold the drug if the BUN mteds 40 rTI9IdL or ~rum uutinine rises
.bow.-l mg/dL
IIfI'8" /l) M)Nu1l1ngK1l A>r Q Nt!1li1l/j I'rIKm for11S lpt(1/{ /l) lin drrii}
Pregn.ncymegoryB
PHARMACOKINETICS (IV)
Onset:I-2h
~k: 1-2h
Halflife: 24-48 h
Duration: 20 h
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HerlIaVFood: Un~
lINIment for O"ferdose: ~rdo~ may It"IUk in (lrdiort-spiratoty alll'lt.No
specffit: thtrip)' is mil.!bIt;p.nimllart tll'attd lymptomatic.Jlly.
510
Implementation
Interve ntions and (Ratio nales)
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511
Tta(h tht j)<Ititnt about thl' nffil forfrequent lab telling.llon oral
antifull9'lk at hOlll!',inlU1J(\ thl' !)alient on th~ OI'~d br periodic lab work.
Wtigh tht !)atitnt d.ily and !!pOrt a weight gain of 1kg or moll' in a 14hour prriod.MNIUII' ima~and output in the hospitalized patitot.(Daily
weight is an auurut measulI'of fluid .tatu nd like. into ac:(ount intakt.
OUIput.and inll'nsiblt ~.Ex(tSW!ewtight gain or rdema II\a)' indicate
rt nal dysfunction.)
InstOJ(tth~
hNdac:he.
Continue to monitol for he patK toool)'; e.g., jaundice, ROO pain, darkent<:!
uriOl',diminished uriOl' OO !pU~ tinniN~ v~tigo, in !)atients on IV or oral
antifungaltlltrapy. (Amilull9'lk may (il/\(' IItpatic toxicity and lfqUill'
flfQutnt monitoring to preY!'nt advtlll' ~I!d . )
urin~.
Tei(h tht j)<Ititm to toilet thl' drug with food or milk but to avoid ac:idic
Iood!and bM'la~. or caroonattd drinkl.
(conrlnued)
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512
UnitS ThelmmuOI'SY'tem
The patien~ lami~, or c:art'9i!'r Ihoukl bf ablr to nate the INIon for tllf
drug;appropriate doll' aocl !<lIfruling;what ad''IW rffrdllO obII'M' for
and when to report; ind the antic:i~ted length of mediution thmpy.
Teach the patient 10 take oral or IOpic:al i ntilungal medication ill 101101'15:
Complete the mtire COU~ ofthffilpy unless otlle!will' in\Uuc:ted.
Se!'ral months 01 oral therapy mily lit rtquirro to adequately treat the
inlrdion.
Avoid or eliminate akohol whilr on oral amilungals toal'Oid hepatic:
c:ompliutions.
D~oIvr oral antifunlj.llloungts (troches) in mouth or rinse with liquids
alter meals aocl at bedtime.lf dentures are worn, r~thrm lit/Oil'
using thrdrug aocl Irav!' out OYl'fIIight. Swilh the liquid drug arouocl
mouth aocl hold in the mouth at Irast 1 minute\ brioll' expKlOrating.
Do not swallow unless inSlruc:ted todo soand do not rinll' the mouth
with water afterwards.
Do not!M oxdusive dll'lli~ when topic:ill i milunljills aft' UII'd.App~
a thin, ~n iaymo theafler:ted aIN.
Allow aflKled skin aft'aI to air dl)' and ww IooII'-fining aocl
"breilthable 1abrio: c:lothelto allow adequate ~ntilation. Gently dean s.t
all'lS with mild SI)lP <l oci water and avoid I'igoIOUl !<rubbing.
[vawte the elfrdi!'lIeSs of drug thmpy by c:onfirming that ~tient goals and expec:ted outc:omes ha!' bffil met (~ Planning1.
SH T~ J5.41U,~oo' JHfor ~ lisltidr0g5 rcwNchrhtst mnqlims~ppIy.
Although rarely used as monotherapy, flucytosine (Ancobon) is sometimes combined with amphotericin B in the
pharmacotherapy of st'Vere candidiasis. Flucytosine can
cause immunosuppression and liver toxicity, and resistance
has become a major problem.
A newer class of antifungals called echinocandins has been
added to the treatment options for systemic mycoses. The
first drug in this class, caspofungin, has become an important alternative to amphotericin B in the treatment of aspergillosis. Approved in 2006, anidulafungin (Eraxis) is
approved for invasive candidiasis. The echinoc::andins are
less nephrotoxic than amphotericin B and have fewer serious adverse effects.
AZOlES
The azo le drugs consist of two different chemical classes,
the imidazoles and the triazoles.Azole antifungal drugs interfere with the biosynthesis of ergosterol, which is essential for fimgal cell membranes. Depleting fungal cells of
ergosterol impairs their growth. The awle drugs are listed
in Table 35.3.
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35.5 Pharmacotherapy
5 13
"n"
AdwfSe Effects
butocooazolt (Fmlsm)
MyIM,OIhm)
t(~(Sprruzol!)
H~to\(o:iY!l:
HoconalOl ~ (DiflOOln)
~OOloazoit
ICf 3 diI)"
I'omilif/i d~rrIIN
(Sporanox)
PO; 200 1119i!li)'; may ioou~ to 200 mg bit (max: 400 mgldily)
kt\O(~ (tim)
PO;200400 mgldily
'bpilil~ i PPIy OII(t
oxitonilat (Oxiltat)
!ft1.lcon.uoit (Ertaao)
tmonazolt (lbOzoI)
lioo:oniZOlt('hgism)
'IOri~ (~nd)
11~1io inciutt
Topltil route:
Dryir1ll ofJiin,5!irlgirrq ~Dr
DpIIimtion lirt, pruriM, urrimrio, (mr 1
dfflnQriD'1
Ug lI:IimIlalMlxfllt!l1
Fluconazole (Dlf/ucan)
,,"'Amajor disadvantl9l'01 ftUiOrwOIt is itl ll't.t~1y IIIIrrow spt<trum of aitivity. A1thoogh it is tffffi~ against ComfIdD aibironl, it may oot be dfctift
against non- oRliam CoriMa spt<it!, whic:h i{((lunt for a lignifium ~=1i 9l' of opponun~tic: fungll inftions.
ADMINISTRATION ALERTS
ADVERSE EFFECTS
FIUloniz* laUlel 1M strious adv~1R tfiriU. NaUl!'a, yomitiog. and dilnhe.J
all" II'pon~d at high doles. Unlikt ketocorwolt, lIt~totOllic:ity is rart wlft flu.
lonaz*, although patimu with hepatic: im~irmtnt should lit monitorM carefully. Sttnns- JohnlOn lyndromr has bern II'portM in ()ititms with
im 1IIJ000uppresmn.
Contr.indi mions: fluronazott is lontraindkaled in Pititntl with hyptlWlll~
tivity III tilt drug. Coidmin~tration with (isapridt is rontraindic:ated. BltalM
most d tilt drug is mll'1ed by tht kidntyS, it should be used cautiously in ~
tiffits with prNJisting kidney dilfillt.
INTERACTIONS
Drug-Orug: Uf of ~with willfarin ma~(,J1III' ilKlNSfd rill: forblHOOg.
HypogI)"(fmia ma,~ ff~iI mnimll'd(OIKulIl'Iltiywith ooain orat
h)tlOl#fmc, n:Wng iflburiclt.fhItonazoIt ImIi may be dKrNIfd with
lonurnnt rilampit or dmmdiMo !/Sf.fhto fflffil of ffn1Ml)l, alfentan~, or
~ may bepiolongN with lOOOIrlaU olIirini!lrililn olftlJ(~.
Lib Tflts:YaiIlfS for AST,AI.,Mld illiillinP phosphat.l\i' may beilmud.
PHARMACOKINETICS
On5t"t :Unknown
~k: 2h
Halflife:2o...SOh
Duration: Unknown
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HerbaliFood: Unknown
Treal mr nt of Onrdosr:Thtre is no SptrifK tll'i tmenl for am:lOlt. Di.t lysis (,J n
lit Ul!'d to Iowt-r the strum drug ~I.
RPM Ie M}M!rl/ngIJ1 fr1f DNlmifll) Pn:m:I FOOII lpKlk Ie ~ drrii}
5 14
UnitS
ThelmmuneSystem
;,
AdVPr... I'ff.... ~
butmafinl> lMffitax)
wk for tiDl'aI
griItofUvin lFulvidn)
Top(,J~ ~ ppIy
naftifi~ (Naftinl
PO;SOO,lro-l,OOO,OOO unilltid
)(
7wHorl~as
PO;150mgdaily x 6- 12wkforonyd\omy(ostI
bid for 4-6 wk
Top(,J~ ~ ppIy
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Prototype Drug
The ra p ~ti c
515
Nystatin (Mycostatm,Nystop,others)
ADVERSE EFFECTS
Wht n g~n topica lly, nyst.tin producn Itw ~ tffl>cts otlltr than mioor
skin irritation. Therr is 01 high inc:idenc:f of contact cltrmatitis, I"I'latftl to tilt
~itl found in somtoftht formuloitions.Wht ngWfnorally,it may calU
diarrfln,r.aulu,nd vomiting.
Contraindi mions: Ihf on Iy comra indication is hypmfnsitiYil)' to tht drug.
INTERACTIONS
Dru;rDrug: Unknown
l.i bTe ts: Unmown
HerbaVFood: Unmown
Tl"fatment of OYerdose: TheI"I' is no !pfCiflC trutment 101 OW'idosr.
111'1'8" III M)NUIlIn9I for Q Millirrq I'rrKnJ fooJs J{lt(tk III rIr/s drr!/)
PHARMACOKINETICS
Onset:Rapid
PNk: Unkna.vn
Halflift : Unkna.vn
Duration: 6--11 h
clotrimazole are aTC drugs of choice for vulvovaginal candida infections, although several other medications are
equally effective. Some of the therapies for vulvovaginal
candidiasis require only a single dose. Tolnaftate and unde cylenic acid are frequently used to treat athlete's foot and
jock itch.
PROTOZOAN INFECTIONS
Proto..,~ are single-celled organisms that inhabit water, soil,
and animal hosts. Although only a few of the more than
20,000 species cause disease in humans, they cause significant morbidity and mortality in Africa, South America,
Central America, and Asia. Travelers to these continenl5
may acquire these infections overseas and bring them back
to the United States and Canada. These parasites often
thrive in conditions where sanitation and personal hygiene
are poor and population density is high. In addition, protozoan infections often occur in patients who are immwlOcomprom.ised, such as those in the advanced stages of AIDS
or who are receiving antineoplastic drugs. Agents for malarial infections are listed in Table 35.5.
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516
UnitS ThelmmuneSyst"",
ICoartml
Adverse Effects
m)'f!9o._o
1tI1lI:I'>HIIiri'ti1l Qr RroInna.!tinn
alO\QQllOlltand progwrillMaiarone)
dKIroqUfM' IAr.llffij
IImxht, myII/giQ
HMrootri.!,m:I1'l!I'!!Wn
IrJdrmyd"joroqufM' IPiaqumin
I~ paoge 743 101 the Prototypt
","'PO
meft<:qJilll'lLviaml
~eJ'!o!herWffk
~,abdomilllllpDin
AVbkKk,llraIMirdia
prillliqufM'
-~
~irdia
I!:molis
~,abdomilllllpDjn
Mrgaloblalli<aormy IClltoprny
l!!!mlboMooenia
quinifM'IQuilamm)
ForoKUiUnads:PO:650mgtid X 3days
Forprophylaxid15mgbid X 6wk
ro!!w N[jQuloCYUl'jil
11m indilite (OOIITIOII oJdom's! effects; !IIderIiriog indiYtes serious adtmse ~m.
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35.8 Pharmacotherapy
of Nonmalarial Protozoan Infections
Although infection by Plasmodium is the most significant
protowan disease worldwide, infections caused by other
protowans affect significant numbers of poople in endemic
Oi>plfl n
5 17
Int.ded mNquito
bOtft petaOn.
f) Plumocl"'n
tr..... IOw...
o "rGzoi,. <IiYide
Ineide MpelOC)1N.
........
"",",-
MtrGZoil......
.......
o
_r
and chiII..
..
MlrozoitM
....,
O~uilObiI..
~inI..:ced
to
,_It cycIto.
o
~
nw-.It
l)mf drio!a, ~
blood"
IlitytonwimWidW:G6PQ(~wI.~ckugiinpM"'"
areas. These infections include amebiasis, toxoplasmosis, giardias is, crypto$poridiosis. trichomoniasis. trypanosomiasis, and leishrrumiasis. Protoz~ns can invade nearly any
tissue in the body. For example, Plasmodia prefer erythrocytes, Giardia the co lon. and &IlIl11loeba travels to the liver.
Like Plasmodium infections. the nonmalarial protozoan
infections occur more frequently in areas where public
sanitation is poor and population density is high. Drinking water may not be disinfected before consumption and
Illay [,t: ~olllamillalt:J wilh 1'~lllul!t:wi rrom I"ullall wa,It:.
In such regions, parasitic infections are endemic and contribute significantly to mortality, espedaUy in children,
who are often more susceptible to the pathogens. Several
of these infections occur in severely immunocompro-mised pa tients, Each of the organisms has unique differ-
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ences in its distribution pattern and physiology. Descriptions of common nonmalari~1 protozoan Infections are
giVl'll in Table 35.6.
One such protozoon infection, amebiasis, ~ff('(ts more
than 50 million people and causes 100,000 deaths worldwide. Caused by the protozoon EnramO<'oo hmo/yrica, ame_
biasis is common in Africa, Latin America, and Asia.
Although primarily a disease of the large intestine. where il
causes uk.ers, E. histolytic" can invade the li\'er and create abSCC5.'ies. The primary symptom of amebiasis is amebic
il)ntff)', a severe form of diarrhea, Drugs wOO to treat amebiasis include those that actdirectlyon amoebas in theintestine and those that are administered for their systemic effects
on Ihe liver and other orga n$. Drugs for amebiasis and other
nonmalarial protozoan infections are listed in Table 35.7.
Although several treatment options are available,
metronidazole (Ragyl) has been the traditional drug of
choice for nonmalarial protozoan infections. In 2005.
tinidazole (Tindamax) was approved by the FDA for treat_
ment of trichomoniasis. giardiasis. and amebiasis. This drug
is very similar to metronida.1.ol e but has a longerdur3tion of
action that allows for less frequent dosing,
5 18
UnitS
Th~
Immune SY"'-""
Assess me nt
Diarrhea
"~
----t--
TNCh the patiffit to IfIIM i fem that does not diminish below l00"F
within 1days, ifl{~i~ng signs and symptoms of inkction, Of )"Il1ptoms
that It'IIlain prt"ll'llt alter taking thf emi~ (OUIII' of the drug.
TNCh the patient to not stop the antibacterial when "kfling better" but to
take tht entirt (OUIII' of the antibaafrial;do oot shall' dom with other
fami~ mtmbtn with similar symptoms;ind f1'tum to the ptovidtr if
symptoms ha~ oot IfSCIlvtd after the f ntifl' rourSl' ofthtrapy.
--+=
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Teach tilt patient to imm~iately rtpOn a fC'/Cf t1wt dots not diminish
below l00"F, or per parameten, or (hanges in behavior or LOC to tht hfakh
ufI'provider.
519
In\!roo tht poatitnt on the nffil for periodic: lab work.Provide a kit and
inslnICIions for homt 1M ifftcal sptdmem a~ requiiM
(ultu~ a~colltcted Irfforrdl\Jgth~rap)' is Stilted or if ,tlrt~d in an
rmtrgtrK' (~.g., OI'l'IWhflming infffiion with s.ig nifK.!nt body-widt
S)'mptoms),u 5QOIl U ftasibly ~~bIt, and ihertafll'f as ordertd b)- the
hulth carr pmridef.
Manitor for h)1ll'l~,itivil)- and allergic: rractions, fijlfCially with first few
doles of any dOl 9 tlNlment (Ana phyiactic: ~actions a~ pm ~bIt.
panicularr,. with tilt first doll'.As parasites dit, ill(rta ~1IC) dianhe.,
abdominal pain,or mills may occur.)
T~i(h tilt patient to tlU tht drug with food or milk but to avoid "idic
foods, he\'trlges or wbonattd drink~ and akohol 1M, ~specially in
patitnuon mtlroniduole.
Ttuh tilt patient to rill' from l,ill9 or sitting to stlndillC) sIow~ toavoid
dizzineslor falls and to awid driving or othtr activities r~iring mt ntal
alfflnffi or physical coordination until tllteffectsof tlltdrug aft' known.
InstrOO tht hospitlliztd pat~nt to call for a5Sistancf prior to gtning out of
bed or atlmlpting to walk alon~.
Ttach tilt patient to promptl)' rrport any palpitations or dizzines~
~irdJ
A,II'Ss tilt poalient's Itlllil panners for infffiion and tIN! rurrmt pannm
to avoid reinfffiion.(Tht infeaion mol, he rt introdlKtd b,the nonlft'attd
saualpoartnec.)
Hal'f tilt patient ootif)' II'lWl p~nners for iSsessrrteclt and tlNlment
Tilt poatien~ family, or ca~giv~r should he ablt to stitt tilt ~ason for the
drug;appropriatt doll' and \(heduling;what aMIIt effec:U to obll'lVl' for
and wh~n to ft'port;and tilt anticipoattd ItllC)th of mtdic:.Jtion therap,.
(Continued)
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520
Unit; ThelmmuneSyu,-""
ADVERSE EFFECTS
ChloroquilK' txIlibin ftw serious .dvtlX' r1itm at low to moderat~ do~. MauIN and diarrhei may oc{ur. At higher rIoIft, (NS and cardiomrular toric:ity may
lit obstrYl'd. S)'IIlptoms ilKludf {oofusion, (oovulliolll, rt'rb:~d rtflOfl, hypotension, and dysrhythmin . (hloroquint u n U IM ~tinal tOliti!)" inr:luding.
blulrt'd yision, photophobia, and difliruity focusing.
Contrainditations: Bfuu~ mloroquin~ u n uu~ minal tOliti!)" it ~ {OIlmindicattd in p.lIiton with prt'~listing ~tinal orl'iswl rlfld dlang!1.k is also
contraindiuted in patients with rt'oal impairment i nd in !hOlt with hy~r>eo
IiliYit-; to tht drug.
ADMINISTRATION ALERTS
Pediatrit dosagt should bt monitort'd c~Iy, IItraIM{hildren all' sus(eptibit to aftrdOlf.
II administrating 1M, injtct into i ~p mus~ i nd aspirate prior to injting medication btuult ofils irritating effts to tht tissues.
Plf90anq Ulegory (
IlerbaVFoo:l: Uotncwn
lINiment 01OYl!rdose: OY!'rdose may bt fatal. S)'mptomuit trfatmeot may
inr:1ucIe anticonvukanu and m Opl!'SlOll for shock. Ammonium chloride may
lit used toidify the uriO!' to hastenellrWoo of {hloroquin~.
PHARMACOKINETICS
1At'\et: 8- 1Dh
Pf,ak:3-4 h
Hall~ile: 15- 2 days
Duration: Variabit (stYeral diYS to Wf~ks)
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INTERACTIONS
1)ug- I)ug: Antacidland taxati"ll!l {ootaini~ aUnintnl and ~ uo
deauif {hkfoquillf atr.crptioo and mUll not tit 9i\opo withi1 4hoIn of 00 0!hK
~iN mayallo in!ml:n with tilt MpOOIf to rabifl 00111'.
OIoplfl n
52 1
Description
Source of Infection
fffilI-<ontaminattct water
fIIranoebo hiJto/yli(D
Primarily infffi' tht I.vgl' int eIIin to c.JUliJg 5oMI! diall'hu; rommooly tri'/ek to tiN' Ii ~r to form
~m iM11t\; rardy trMis to other OC9im sud! as tiN' brain, lungl,lX kidllt1
CryptolplXidOli!
AmdNsis
fffilI-<ontaminattct water;
0~lpOridumpornJm
1_
fffilI-<ontaminattct water
B~e offnnaif,Anop/ItIt5
mosquito
Trichomoniasis
Giardiasis
GiorrlQ II!mb6o
Malaria
i'll1OOil1ll11variou! !pKitI)
klIopIosmo gondii
TOOIomI:nn ragilUll"rs
Trypanosooiasis
TrypDl105IImQ f!lIli (Ammo)
'm
TrypIIl1OSOmQ bf!KellAfriYn)
areas lacking high standards of sanitation. Helminthic infections in the United States and Canada are neither oommon
nor filtal. although drug therapy nuy be indicated.. Drugs
used to treat these infections, the antht'lmintics, are listed in
Tablt' JS.8.
35.9 Pharmacotherapy
of Helminthic Infections
Ht'lminths are classified as roundworms (nematodes), flukes
(trematodes), or tapeworms (cestooes). The most common
iockqJinot (Yodm:in)
Adverse Effects
NlWl#II, K>miring, htadQcM, tlnirlflS
1'0;2,1)-750 mg tid
rifunimox (l.Jmpit)
tramiml kutooerit
paromom,un lHumatinj
pl'fltamidine (Peotam,
NebuPl'ntj
sodilltl stboghKonate
1M; 20 tngtWday
I!Ig1axi>ilX IIfIIb~lilX
ll'ulioorria byoodvrnria abKmQr pain at iniraioo lhr
hlDOtmlion n~[l!~iIi!x
(PtntOltam)
tinidazoll' (Tilliamax)
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UnitS Thl'lmmuneSyu"",
I Metronidazole (Flagyl)
ADVERSE EFFECTS
Ahhough adRiII' efferu occur relatiYely
INTERACTIONS
Drug-Drug: MEtronidazoIt iueram with oral antiroagulanll to poIaltiar:e
h)'poprothrornbilfnN. In arnbination with akohol, II" oW! ltII'dications that may
<DIUin akrtlol, lMrOIIilazolro may eIictt a dsUftram JNOion. ln palierlll taking
lithium, thf drug may flf'liltlithium ~
lab T15u: Mtuonidazolro may dKJNII' '/iUs for AST and ALI
IlerbaVForxi:iJnknown
Treatment ofOYerdose: There is 00 sprcifK tlNtllll'l1t for O'/~rdo!e.
HmfIlMyMfimgKt IIIr ~ /UJhlgl'IIXe\lkXIIIIpKlIII.1I UIIIIfI!9.
PHARMACOKINETICS (POI
()Jset:Rapid
Pt'.k:l - lh
Hall~ifd....8 h
Duration:Unknown
Adverw Effects
--.
ivffinKiin (SIromKlol)
Q mtbtndarole(Vermox)
pruiquantrl (Bitriddr)
aDtiwl~!IIi tIIIltlIl~1lIIl:
(Y~aillllml!tlIlIII:
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the standard treatment. Phannacothernpy of emerobiasis includes a single dose of mebendazole, albendazole (Albenza)
or pyrantel (Antiminth, karel, Pin-X, Pinworm Caplets).
like protozo~ru, helminths have several stages in their life
cycle, which include immature and mature forms. Typically,
the immature forms of helminths enter the body through
the skin or the digestive tract. Most attach to Ihe human intestinal Iract, although "",me species form cyst. in .keletaJ
muscle or in organs such as the liver.
Not all helminthic infections require pharmacotherapy,
because the adult parasites often die without reinfecting the
host. When the infestation is severe or complications occur,
pharmacotherapy is initiated. Complications caused byextensive infestat ions may include physical obstruction in the
L IFESPAN CONSIDERATIONS
~ Prototype Drug
523
intestine, malabsorption, increased risk for secondary bacterial infections, and severe fatigue. Pharmacotherapy is targeted at killing the parasites locally in the intestine and
systemically in the tissues and organs they have invaded.
Someanthelmintics havea broad spectrum and are effective
against multiple organisms, whereas others are specific fora
certain species. Resistance has not yet become a clinical
problem with anthdmin.tia.
LIFESPAN CONSIDERATIONS
IHUIt
Mebendazole (Vermox)
ADVERSE EFFECTS
BfloilM 10 littlt of th~ drug is absorbtd, mtbtnduole dots not gtlll'liIlly (ilM
mious systemic siclt rifrm. A; lilt worms dif, IOmt abdominal pain, dill~n
sion,and diarrllea may he uptriencrd
Contr aindi (ations: Ih~ on Iy (Omri indic:atiln is hypm~mitiyjty to the drug.
P"'9n .nqca~ory(
PHARMACOKINETICS
Onsrt:Unknown
~k: 1-7h
Halfl~d-9h
Duration: Unknown
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INTERACTIONS
Dru;rDrug: UrboImmpiIll' and p/IM)1oin (0)11 ilKffiR tilt mttaboIism of
......"".
libTI'S1S:Unmown
HI'IiIi VFood: H~1at foods rna, inrrNlf the abIorption of the drug.
Treatm~nt of lmrdos~: ThM' is 00 !pf(iIK tft'itment for OY!'rdos~ .
S14
KEY CONCEPTS
The nu mbered key concepts provide a succinct summary of the important points from the corresponding numbered section
wIthIn the ch~pter. If any of these points are not dear, refer to the numbered section wilhin the cha pter for review.
15.1 Fungi have more complex physiology than bacteria and are
unafft'ded by most antibiotics. Most serimu; fungal illfe<>
tions occur in patients with suppressed immune defenses.
3,5.7 Malaria is the most common protozoan disease and requires multidrug therapy owing to th e complicated life
cycle of the paras ite. Drugs may be administered for pro phylaxis. and therapy for acute attacks and preventIon of
reklpses.
35.S Treatment of non-Plasmodium prot owan disease requires a different set of m edications from those used for
maLuia. Other protowan diseases that may be indications
for pharmacotherapy Include ameblnsls. toxoplasmosIs,
gIardiasis, crypto sporldlosis, trI cho mo niasis, trypanosomiasis, and leishmaniasis.
3S.9 Helminths are pa.rasitic worms that cause significant disease In certain regIons of the world. The goals of pharma _
cot hera py are to kill the parasItes loc~lly ~ nd to dlsrupl
their life cycle.
~nd
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3. antacids.
4. oIoohol
Drug5forFur.galProtozolf1,~nd
Helminthic InlKtlons
525
derstands that this medication is highly toxic to the patient. What are three priority mmlng assessment areas for
patients on this medication!
EXPLORE
LiiglilllitiOnjmr- ----,
Unklr. MlI1VIta!5
RIlO'Sler yo:u acteS:! mOl! Imm III/! Iront I'l rour 0001< at
www..mynll".mgkilcam..
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DRUGS AT A GLANCE
LEARNING OUTCOMES
Transc~ptase
NonnudeosldeReer1e Transalpuse
Inhibitors
f1IlI}t5j}
FuslonlnhlbltoD
Pt1II5JlJ
6.
7. USIl thll nUl"$ing proceu to care for patillnts rllClliving drug thllrapyfor
viral Infections.
KEY TERMS
immunedef1tiencysyrdrome (AIDS)
JllXJ'5l&
.cq ui ~
antimroviral (JlJlJd18
,.psid paqr517
CD4 l'fCfptor fllXJ'518
hepat~ is p!XJ'54J
highlyactin
,.,."
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HIV-AIDS fllXT5l1J
human immuoodencifnC)' virus IHIVJ fIIXT 5l1J
influellU fllJlJ'540
intracei lularpara~tf fllJlJ'517
protNlli fllJlJ'5l1J
rntrSur ansaipl a~
yiraiload fllJlJ'519
f irion fllJlJ'517
yirus {JIJ1t 5lJ
fllXT518
CIIopltlK
iruses are tiny Infectious "gents capable of causing disease In humans lind otherorg.nlsrns.After Infecting an
OIU9sf"'';'lr~lInfKtlons
527
The host organism and cell are often very specific; it may
be a single species of plant, bacteria, or animal, or even a sin_
gle type of cell within that species. Most often viruses infect
only one species, although cases have been documented in
whidl viruo;es mutated and crossed species, as is likely the
case for HIY.
Many viral infections,such as the rhinoviruses that cause
the oommon oold, are self-limiting and require 00 medical
intervention. Although symptoms may be annoying, they
resolve in 7 10 10 days, and the virus causes 00 permanent
effects if the patient is otherwise he;>lthy. Some viral infeo:;tioru., however, require drUS thuilPf to prevcntthe infoon
or to alleviate symptoms. For example, HI V is uniformly fa.
tal if left untreated. The hepa titis Bvirus can cause perma.
nent liver damage and increase a patient's risk of
hepatoo::eUular carciooma. Although not life Ihrt3tening in
most patients, herpesviru!K'S can cause significant pain and,
in the case of ocular herpes, pennanent disability.
Antiviral phannaootherapy em be extremely challenging
because of the rapid mutation rate of viruses, which can
quickly render drugs ineffoctive. AI$O complkating therapy
is the intracellular nature of the virus, whkh makes it diffi.
cult to I!liminale the pathogen without giving excessively
high doses of drugs that injure normal cells. Antiviral drugs
have narrow spectrums of activity, usually limited to one
specific virus. The three basic strategies used for antiviral
pharmacotherapy are as follows:
Prevent viral infections through the administration of
vaccines (chapter 3:ZOO).
Treat active infections with d r ugs such as ilcyclovir
( Zovirax) that interrupt an aspect of the virus's
replication C)"de.
For long-term infections, use drugs t h.:lt booS( the
patien!"s immun e response {LmmUnOSlimulantsJ $0
that the virus remains in latency wilh the patient
symp tom free.
PHARMFACTS
Viral Infections
Appnxima~ 85\110 of Idulls hnor serologic Mden<:e of ~M by
HSV1.
About.5 million ~iclLns.~ infected with guiUI htJllts-Ontof
~ry 1M of tile toul.doitKmt.nd Idu~ pop.L~tion.
(;rnit.l Ilerpts is men [ommon in WOnItn th.n in men. .nd in Afriun
Amtrium th.n in other ethnic gJOUpi.
About900,OOO Amerium.~ [Urltnt~ living w~h HIV inftions,and
.bout 010,000 ntw infection LOUIJr N<h )'tar.
Roughly ~of ntw HIV infectiom occur in mu;tllt largest rish.tfgOry
is mtn who Iw~ Lee with othtr men.
or the lIN HIV infections in WOmtn, 7S"'.J1! ..:quiffd thl'OUgh
htttrosnuallDl1ll<t
5R:t tilt btgiooing oltilt AIDS tpi:ltmic, II"IO!t tlwtl20 milon people
~induding4S0,OOOAmtriuM,lIMditdolthis~.
,. F1gun36.1 StJUctureofHfII
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UnitS
ThelmmuneSyu,-""
becomes incorporated into the host's DNA. It may remain
in the DNA for many years before it becomes activated to
begin producing more viral particles. The new virions eventually bud from the host cell and enter the bloodstream. The
new virions, however, are not yet infectious. As a fmal step,
the viral enzyme protease deaves some of the proteins associated with the HIV DNA. enabling the virion to infect other
HIV-AIDS
Acquired immun~ defkiencysyndrome (AIDS) is characterized by profound immunosuppression that leads to opportunistic infections and malignancies not commonly found in patients
with health), immune defenses. Antiretroviral drugs slow
the growth of the causati,"e agent for AIDS, the human immuno
deficiency irus (HIV), by severul different mechanisms. Resistance to these drugs is a major clinical problem, and a
pharmacologic cure for HIY-AIDS is not yet achievable.
T4
lyJJll'hu~rl"'.
Viral
~ 'o.~ ",".'~m.
Cytopl .... m
o
.. Figure 36.2 Replication of HIV
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recognizes that the cell is infected and kills the T4 lymphocyte. Unfortunately, it is too late; an HIV-infected patient
may produce as many as 10 billion new virions t'Very day,
and the patient's devastated immune system is unable to remove them. Knowledge of the replication cycle of HIV is
critical to understanding the pharmacotherapy of HIVAIDS, as shown in .. Figure 36.2.
Only a few viruses such as HIV are able to use reverse
transcriptase to construct DNA from RNA; no bacteria,
plants,or animals are able to perform this unique metabolic
function.AU living organisms make RNA from DNA. Because
of their "backward" or reverse synthesis, these viruses are
called retroviruses, and drugs used to treat HIV infections are
called antiretroirals. Progression of HIV to AIDS is characterized by gradual destruction of the immune system, as measured by the decline in the nwnber of CD4 T-lymphocytes.
Unfortunately, the CD4 T-lymphocyte is the primary cell
coordinating the immune response. When the CD4 T-cell
count falls below a certain level, the patient begins to expe-
OIIpttr36 Oru9,forVlr.llnfKtl"",
rience opportunistk bacterial, fungal, and viral inflions,
and certain malignancies. A point is reached at which the
patient is unable to mount any immune defenses. and death
ensues.
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Promol~
""'-'"
i
~
I
;1
S]O
UnitS TtelmmuOI'S)"tl'm
Drug
Adverse Effects
NONNUCLEOS ~ DE
dtiaYirdillf IRecri,tor)
d"ilYirrnzlSullin)
t1raviril~ (lnl~)
CNSlOli!:ity fdavirmzl
III'Yir.pi"" (Vlr.m,,,,,)
abaulir (Ilagen)
didano~ot (\'"00,001)
PO;l1Hoomgbid
mltridtabillf ([moo)
Forriqw,~wrotntJl,myolgi~,flCU5t4~
abdomimll~il1, 1mIi~~ ~nomio, roll!
IamivLdot (Epi'li",lTQ
tftlOfiwi (Vill'adj
PO;loo mg/day
aliUnavi (R~aw.)
PO;400mg/day
darunavir (Pluistaj
fMamprmavir (Lniva)
lmoll:1,8OO rngIday)
ildinawi ]Crilivin)
PO;800mgtid
IopinaYir/ritor\lYir (Kaltlra)
otVirapi~
IIflfinawf lViraapt)
PO;750mgtid
ritor\lYir (Norvir)
liQUinaYirlmiu~)
tpranaYir lAp~l'IIS:
toMirrm(fuuon)
SlDwtaotOUs;90 mg bid
llliravm: (SMntry)
rak~raYir (IItnt~)
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CNptfll& Oru9.lorvlr.tlnIKtlom
53 1
two NRTIs
Treatment failures commonly occur during antiretroviral
therapy. The primary factors responsible for treatment failure are inability to tolerate the adverse effects of the medications, nonadherence to the complex drug therapy regimen,
emergence of resistant HIV strains, and genetic variability
among p.1tients. Pharmacologic options available for patient> with treatment failure are limited. Higher doses are
generally not indicated, because they lead to an increased
incidence of serious side effects. Ideally, the patient is
switched to at least two drugs from different chemical
classes that they have not yet received, but this option is not
always possible because there are so few drug classes available to treat HIV-AlDS. The therapyofHIV is rapidlyevolving; thus the nurse should consult current medical reference
sources for the latest treatment guidelines.
Drug manufacturers have responded to the need for simpler treatment regimeru; by combining several medications
into ~ single capsule or tablet. For example, one of the newer
therapies combines three HIV-AIDS drugs, manufactured by
two different companies. Atripla combines efuvirenz, emtricit.1bine, and tenofovir into a fixed-dose tablet. Approved by
ADVERSE EFFECTS
Zidovudint has tht pottnri,1 for miolH adl'f~ tift"! and hal ~ril FDA
bla.c:k ~OII w,mingl. Thf df119 can (i!~ Sf'Itfl' htmatologK tOlicity at high
do~;inemia andnWlropeniaa~(Ommonand m.ylimitthfrapy.~(iIft
val poiuOd.LM with otIltI inti"l uovirai iMJi'Illl may IiIUII' laniu (iOOIis RlfYeI"l
~withIlNnM.
Halflift: I h
Duration: Unknown
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UnitS
Thl'lmmuneSyu"",
...
Prototype Drug
EfaVirenz (Sustlva)
PHARMACOKINETICS
il1setRapid
Pf,ak:3- 5h
Half~ife: 51- 76 h
Dur.lllion:24 h
ADVERSE EFFECTS
(HSaoM~ rffe(\S a ~obsrl'/~ in a! leoH! SO% of the patients whr-n fint initioiling thrra py, in(kiding sJrrpdisordrB, nightmarrs, dizzilll'l~ ~rb:rd abilit)' to
mnummt, and <!elusions. T~ Ymptoms gradually diminish afitr J--4
WffD of therap)'.likr other drugs in this das~ ruh is (ommon and musl bt
moni!~ camully to plrl'!'nt!he rIe~pmrnt of I>Mf"r blistl"ling ordrsquamation.
Contraindi(ations: Ef,virenz is a known trratogl"ll in laboratory animals and
rrust IlOl bt giftn to prrgnan! patienn. Patients in thr (hild-btaring ~m
!hould btadvill'd !o usr ~Iiable methods of birth (ontrol to avoid prtgnanq.
INTERACTIONS
l)ug-l)ug: Palifm who iftfKeimgan!~ti< mfdicatioollMaboliNd by thr
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Orug,lorvr,.lInfectlo,,,
sn
LIFESPAN CONSIDERATIONS
pll'Kribed medication plan. Drug rompiialKf is diffiruk for most peoplt oo{f
thty frrl writ patifntl may ill' mon pront to ~ip do~ for various lI'.HOIIl
Ma ny factors "n mharKf thf probabilil)' that the patirm will adhm to tll'atIIIl'IIt.For rumplt, a multidiKiplillilY allfSllIIl'IIt (an \(1!'t'O p.ltirntl for dIopll'nion, akohol or drug aoolol', or negatiW' attitudes,.nd intt'M'ntion I ran ill'
initiatrd to minim~ tht imp.!{l on {OmplialKf. Eduration at an appropnatt
k-Iel is nsrmiallO tht patitnt "n understand tht dilol'alol' prom! as 'MI111
thr rolr t~ medicatiorrs pliy in IKUring a polit~ oukomr. Developing trull
and oprn communication bttwrrrl the p.ltirntand t~ ~,kh call' proYicIrf is
nsrmial to improving thr {!worr-s of drug rompliaort and to lI'arhing common theraprutic goals.
~ Prototype Drug
36.6 Pharmacotherapy
with Protease Inhibitors
Near the end of its replication cycle, HIV has assembled all
the necessary molecular components to create new virions.
HIV RNA has been synthesized lISing the metabolic machinery of the host cell, and the structural and regulatory
proteins of HIV are ready to be packaged into a new virion.
Th@rapeutic(lass: Antiretroviral
ADMINISTRATION ALERTS
PROTEASE INHIBITORS
PHARMACOKINETICS
Onset:Rapid
~k: l-4h
Halfliff:S~h
Duration: 12 h
ADVERSE EFFECTS
Kairul is 'MIl tolrratrd by molt patirnts, Ind the most fno~mly II'pOrtrd
prGblrm Kdianile . He~ and GI-reIat~d elleru art common, inckJdirog
oaum, wmiting..d)'lpepsia,and abdomillil pain. Hyprrglyrrmia hal been reponrd Ind Kalttra may WJIoI' or WOIWll!)'IIIplom! of diabetrs mellitus. A
lipodystropll)' Iyndrome may O(cur lhat is moc:iated with hypel9l){rmia Ind
fat lI'distribution. l'an(lI'atitis is 1 ra ~ though potrmially fatal,adYtrw ~nt.
Contraindications: l'atirnts with l~r impainnrm, ~spe<ially thoW' with preexisting firal hepatitis, should ill' wclul~ mooitOll'<!. Htpatic rlll)'m!' 1r~1s
should br regulartyffalWlrd in t:hr!oI' patirnts to jlll'Vrm h~pnir failu~. PItirnts with diaill'tes should ~ monitored II'lJIlarl)o bruulol' K.iltm may uarfflIatr this condition.BII'III ferding is{oomindicatrd dUl' 10 th~ potrntial risk
of transmitting HIV 10 thr nrwbom .
INTERACTIONS
Dnq-Drug: l(fina'lir ~ metMfI)' mmbolinod by htpaticl'lll)'meI,and augsthal
IIIdfI90 lIfpa!k mftabolism II\a1 in!mct with K.1Iw.I. ~ that II\a1l1'rtKt 1M
~lofthfantRtnMralinWclfOf'lirapine,framnz.~
""'ill 0(
Siatim shoUd not br _nillerl'd with Katelra duI' 10 an iooNsed rill; for
1Il)'OpiI!hy. Conruntnt 1M of rifampin may lower thf !lffrtinrl!2; of Kalwa.
~!I1tia1l)' lilHlmtl'lling ltf\rI1)1Irnial rna, ouurifKatmilll\fd{onamrl\)'
";!h (~,<i<lp"ido, pi""""",,.and many antidy<rhytlu,i< OI)Mn.KaIoualllO)l
iooNSt adv~ ef1K1161Oda1ed with s.e4Ktivf loI'IOIorin rflllllal:l inhibitors
lSSR~), triq(ir antid!pressMlts,ancI p/IfnoJhiazinrs.
Lib Tests:1ot.Ji dloItstaoi and~ rna, inaNlf.
coouaioticatfd.
Treatmtnt of ImrdOSf: Theil' is 00 spe<ifK IlI'almrnl for OYerdosr.
1II!(pf Ie M)Nurllllgm IbrQ Nurlifll} I'nxtl.! fm Jjlt{1k Ie rNs d~
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UnitS Thl'lmmuneSyu"",
Assessment
Inftction
Activity IntoltralKf
Fatigut
"',;",
Imbalanced Nutrition,l.tss Than Body i!fquirl'llll'nu
Oeficitnt FluidVoume
Oiarmra
ImpaiR'd OrallNKus Membranrs
ImpaiR'd Skin Intrgril)'
Insomnia
SocialllOi.Jtion
Confusion [iKute or (hronic:)
IlII'fieur.e Therapl'lltic: RegimenMul.Jgtment (lfi.Jtfd to (ompieJ
medic:.Jtion Ifgimen and dill',u rrmment)
(lr,fiOtnt KnowIedgt (reIattd 10 diseast proo:fIS,tranmlissiln, and drug thmP'll
Hopelessness
Spiritual DistR'SS
R~k for InjJry, Risk for Falk (lfi.Jtrd to adw"ll' drug ~cn ordill',u)
R~k foruregil'ff Role Strain
--+-=
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CNpttrlo6 Dru9,lorVlrallnlec:dom
535
Continue to monitor periodic: lab wor\I;;hl'p;ltic: and rtoal fUnction um, CBe.
C04 (ounl5, HIV RN~ ma)'~lipid ~Is, ~rum amyb~, C&S if(onrulll'nt
in~tionsil~ prt"IeIl~and gllKo~.(Drugs ulf<l for the lR'atml'nt ofHIV illI'
htp~tit: . nd I"I'nal tolN:. BoIM.'!N1TOW wpprtSmn and It'IIlking blood
dysc:riIsiH, partic:Ulillly anemia .nd ltukoptnia,all' abo .amS!' tffts and
will k monitorrd by eBe Lipid Icvds ~nd ICrum .mylase will k monito~
to asses for p;ln{lI'atitis and gkKOI~ Im-b chl'dtd for h)"lll'rgl)'lemia.j
Monitorfor h)1ll'l"~nsitivity ind ililergic: lI'"tions,tspttially with tilt first
~ of.ny ilnti~lIl'/iral or proteom inhibitor. Cootinul' to monitor the
p;lti!1lt as IIffiItd bastd on tilt drug usrd or tilt patieni's{ondition.
(Anaphy\olaic: I"I'<lctionsarf polsiblt,panic:ularly with zakitabiot. ~USI'
~.aioos milY not .lwil)"! bt prtdiuilblt, cilution ~nd fll'quent monitoring
art !1~ntial to l'OIUrt prompt trNtm!"Illj
Continue to monitor for IItpatit and II'IIiII toxitities.(AntirtirOOrab <l nd
prote. ~ inhibitors m.y be hepatic: ilnd lI'IIil toxic: ilnd ~uift' fll'qUtnt
monitoring to pll"<'tnt advers~ ~ffts.ln{lNsing fkJid intalct will pll"<'tnt
drug icrumulilUon in kidnl')"i.)
Continue to monitor for dermatoiogic: tffts ilKluding ft'd or purplish skin
ralh, blisters,or pr~ling skin, induding oral muc:ous ml'mbr'III'I ..wm oral
murous membriln!1 for signs of ltomatitis, i ldrug tffffil or
immunosuppl!"lmn may Il'IUk in thl' amgrowth of oral fIora.lmmtdiateiy
~port ~rt lilShts.!'Spttially ilSlCKiattd with blilll'ring. (Thesl' drugs may
caUSI' Ygnifiunt dermatoiogit eflem inc:ludingllomatitis,.nd
Stel'l'Ol-.Iohnson s)'lldlOll"lt, iI pottotiilily fillil ronditionJ
Ttath tht p;ltitm to inlpffi oral cavity at 1t.1I on~ a day and maintain
II'9IJbr denull'tiIm1. Maintain good oral h)'gient .nd rin~ mouth with
plilin water or IOknion ill PlI'I(rib!1l by tilt hukh call' provider after
fating.U~ protfltil'l'(lothing for sun fllpOsure and immrdiatei)' repln
any signific:.m rashes or sunbumtd apptaralKl'.
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1Nch tilt patient to!.lkt the drug with food 01 milk l 'PPlOpMt or \(I
ukt drug on in empty stomadJ with, ill gins of Wilter.Arroid IC_ Ioods
and ~ 0I~!td IImks, wiml mllYUIIIt S!omid! upstt.
Enr:our'9t the p,\itnt \(I try snwll, frequmt meals,.midl
be bttttr
tolfratrd Nn ffwrr,laIgtr mNk.Hi\Jhnloric foods ,nd wppltlllflltil
IImr'9ts (e.g.,Boost 01 Emure) may help ,dd ~', ulorits Ind
wpp/y iddimnalllJids.klist thf plItimt in ob~g , dittary
consultation ~ ~ if IIiUSti OIdiirrhu makes lnainuining intilkt
N,
diffiru~.
--+-
The pititnt, family,Of {.regioItf should be .ble to ltaft tht rt~on for tilt
drug;i1J11lrt111rWtf dose ind KhtOJling;wlwt ~ tffHts kl obII'M" lor
.and when to rtpOrt;ilnd tilt inticipi~ length of mtd"1UIIion thera",.
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o..p!tr]&
As the newly formed virions bud from the host cell and are
released into the surrounding extracellular fluid, one final
step remains before the HIV is mature: A long polypeptide
chain must be cleaved by the enzyme protease to produce
the final HIV proteins. The enzyme performing this step is
HIV protease.
The protease inhibitors (PIs) attach to the active site of
HIV protease, thus pre~nting the final maturation of the
virions. The virions are noninfectious without this final
step. \'/hen combined with other antiretroviral drug classes,
the PIs are capable oflowering plasma levels of HI V RNA to
an wldo1ectabl", range. Sin"" their development in 199:;, the
protease inhibit ors have become essential drugs in the treat~
ment of HlV-AIDS.
The Pis are metabolized in the liver and have the potential to interact with many different drugs. In general, they
are well tolerated, with GI complaints being the most common side effects. Various lipid abnormalities have been reported, including elevated cholesterol and triglyceride
levels, and abdominal obesity. Cross resistance among the
various PIs has been reported.
All PIs have equivalent effectiveness and exhibit a similar
range of adverse effects. The Panel on Antiretroviral Guidelines for Adults and Adolescents reconUllends the use of
atazanavir, fosampren.1Vir, or lopinavir as preferred drugs
for the initial treatment of HIY. The initial choice of protease
inhibitor usuall), includes low doses of ritonavir. Addition of
small amoWlts of ritonavir allows less frequent dosing intervals and increases the plasma concentration of the primary
protease inhibitor. This is known as ritonavir boosting.
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ONg,lorVI,. lInlectlo,,,
537
In 1994, clinical trials determined that perinatal transmission of HIV could be markedly reduced through pharmacotherapy. The risk of transmission may be reduced
approximately 70% using the following regimen:
- Oral administration of zidovudine to the mother,
beginning at week 14 of gestation and continuing to
week 34 of gestation.
- Intravenous administration of zidovudine to the mother
during labor.
_ Oral administration of zidovudine to the newborn for 6
weeks following delivery. (HIV infe~tion i, estubli,hed in
infants by age 1 to 2 weeks; starting antiretroviral
therapy more than 48 hours after birth is ineffective in
preventing the infection. )
This original regimen to prevent perinatal transmission
has been supported by subsequent research and remains essentially unchanged. The specific drugs chosen depend on
whether the mother is treatment experienced prior to the
pregnancy and on the results of resistance studies. To date,
there does not appear to be an increased incidence of congenital abnormalities or malignancies among the children
born to women receiving this regimen. If the HIV infection
is diagnosed earlier than week 14 of pregnancy, the patient
is usually placed on HAART combination therapy, with zidovudine as one of the drugs in the regimen.
Since the start of the AIDS epidemic, nurses and other health
care workers have been concerned about acquiring the infection from their HIV-A1DS patients. Fortunately, if proper
precautions are observed, the disease is mrely transmitted
from patient to caregiver. Accidents have occurred, howe~r,
in which health care workers have acquired the infection by
exposure to the blood or bod)' fluids of an HlVinfected pa
tient. Approximately 56 cases of patiem.to-health-careworker transmission have been docwnented in the United
States following occupational exposure. Although the risk is
very small, the question remains, Can HIV transmission be
prevented after accidental occupational exposure to HIV?
The answer is a qualified yes.
The success of postexposure prophylaxis (PEP) therapy
following HIV exposure is difficult to assess beause of the
lack of controlled studies and the small nwnber of cases.
Enough data have been accumulated, however, to demonstrate that PEP is successful in certain circumstances. For prevention to be most successful, PEP should be started within
24 to 36 hours after exposure to a patient who is known to be
HIV positive. The exposed health care professional should
receive a b~.Ieline HIV RNA level as soon as possibleafterex_
posure and subsequent follow-up testing as reconunended.
If the HIV status of the patient is unknown, PEP is decided case by case, based on the type of exposure and the
likelihood that the blood or body fluid contained HIY. In
some cases, PEP is initiated for a few days, Wltil the patient
can be tested. PEP should be initiated only if the exposure
53 8
HERPESVIRUSES
Herpessimplex viruses (HSVs ) are a family of DNA viruses
that cause repeated blister-like lesions on the skin, genitals,
and other mucosal surfaces. Antiviral drugs can lower the
frequency of acute herpes episodes and diminish the intensity of acute disease. These drugs are listed in Table 36.2.
36.8 Pharmacotherapy
of Herpesvirus Infections
Herpesviruses are usually acquired through direct physical
contact with an infected person, but they may also be trans-
L IFESPAN CONSIDERATIONS
DN,
Adverse Effects
SYSTEMIC AGENTS
Q oK)'dlWi (lO'li"axj
ddofcwi I'mtide)
famddoYir (ramlir)
foIamet lFolGllir)
~ddcwir (CytIWrnt')
NQlIlfo,lI1miring.diorrhM, irfOOhe,pllnooo
ifiecrioo fire! (ptnflftfllJ O9fIIrl"J
imlflmmo~OfIIX
PO;1 gtid
IV; 5mgJ1o;g nfusrd IWrr 1h bid
'fai<l(ydlWi ('hkll'J)
TOPICAL AGENTS
doc:osanoilAbrm)
idoxmlH' ([lrndid.lk!plrx)
TOjiul; 10% lJI'am applied to {old lOll' up to fi.". timel/day for 10 days
TOjiu~ 1drop in 00 ~ MIl hall" cUing ~mg hoo.n <lnd N~ 1 hr
--
PhoIophobia,k@op;Ithy,andtdffi\aofC'lrid}
(lKularagen!51
=,~,'c.::
drop in 00 ~ MIl 2 hdll"ing waking hoo.n (max:9 ctopsI
,="'
='_L___
triftmne lViroptic:) _ _ _-'-'Copc"
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Chaptfll&
~ Prototype Drug
OrugslorVlr.llnlectlorn
539
application to herpes lesions, although therare not a. efIeetivt' as the oral forms. In immunocompromised pati~nts, IV
acyclovir may be indicated.
RecurrenT herpes lesions are usually mild and often requ ire no drug treatment. If drug therapy is initiated within
24 hours after recurrent symptoms first appear, the length of
the acute episodt' may be shortened. Patients who experience particularly severe o r frequent recurrences (more than
six episodes per year) may bfnefil from low doses of proph ybcticantiviral therapy. Prophylactic therapy mayalso be
of benefit to immunocompromised patients, such a; those
receiving antineoplastic therapy or those with AIDS.
Herpes ofthety\' is the most common infectious cause of
cormal blindness in the United Sl:!tes. Ocular herpes causes
a p ainful, inflamed lesion on the eyelid or surface of the eye.
Prompt treatment with antiviral drugs prewnts permanent
tissue destruction. As with genital herpes, once patients acquir~ ocula r herpes, they often experience recurrences,
which may occur years after the initial symptoms. Ocular
herpes is treated with local application of drops or ointment. Trifiuridine (Viroptic), and idoxuridine (Dendrid,
Herplex) are available in ophthalmic formulations. Oral
acyclovir is used when topical drops or ointments are contrairxlicated. Uncomplicated ocular herpes usually r~solves
after 1 to 2 weeks of pharmacotherapy.
I Acyclovir (ZOVlrax)
ADVERSE EFFECTS
A~
by t~ fDA in H8l ~I 0lIl' of t~ finl ~mivirll drug~acycloYir is limitt<! 10 pliarmac:Ollierap)' for ~rpmillM1. for which it is I drug of dIoic:f.1t is
moSI eff~ 'gainll HSV-l and HSV-2, ~nd fffKtiYl' only at high do~
~glinll (MV and varierlla lOIter. By p~ting viral DNA s)'rllhesis,acyclovir dr(INSfS t~ duration Ind ltl'frit)' of aMf ~rpes tpilodrs. Whtn giftn for prophylaris. it ml YdKrNl!' t~ frequeoq of herprs appNranc:~ but it does not
<Urt tho pal;' nt It is "".ilobk .,. 5% oinl"",nl for opplic:.nion to .<lM: lesions.
in oral form for prophyln~,. nd u an IV for ~rr episodes. kuUS!' of in shon
half-life,acydOYir is somftimes .dminillmd orally up 10 fiY! times i day.
ADMINISTRATION ALERTS
When gil'l'ft 1V,!ht dng may "US!' painful inflammation of vesl!'k 'I th!'
Sitf of infusion.
Adminil!fr around !hI (lock, eI'l'ft if SitfP is inttrrupted.
Adminil!rrwith food.
PlI'9nilK)' "'t9ocy (
PHARMACOKINETICS (PO )
Onst1: Unkna.vn
~k: I.5-2h
Halflife: l.5- S h
Duration: 4-8 h
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INTERACTtON 5
Dru;r~rug: (rorunenl !til' of acydoW willi ntp/IrotoIK agt'IIu Ihould bf a'I<IiCfd.
HerbaHood: Unknown
Treatment of OYerdos@: TherrisoosprcifKtrratmtntforOY!'rdosr.
IItftt to M}Mmlnqm for Q Mmi"ll'rlxm fooJ5lp1k to rlrls dr>Jq.
54 0
INflUENZA
Influenza is a viral infection characterized by acute symptoms
"'.0
Iu
~hurl"Jl
Ill" nUfmai 7
VIRAL HEPATITIS
Yiral hepatitis is a common infection caused by a nwnber of
differt'nl viruses. Although each virus has its own unique
dinical features, all hepatitis viruses cause inflanunation
and necrosis 01 liver cells. Symptoms 01 hepatitis may be
acute or chronic. Acute symptoms include fever, chills, fatigue, anorexia, nausea, and vomiting. Chronic hepatitis
may result in prolonged futigue, jaundice, liver cirrhosis,
and ultimately hepatic failure.
36.10 Pharmacotherapy
of Viral Hepatitis
HEPATITIS A
Hepatitis A virus (HAY) is spread by tht' oral- fecal route
and causes epidemics in regions of the world having poor
sanitation. Outbreaks in the United States are most often
sporadic events caused by the ,onsumption of contaminated food.
Although approximately 20% of HAY-infected patients
require some hospitalization for symptoms related to the infection' most recover without pharmacotherapy and dewlop lifelong immunity to the virus. Fatalities due to
chronic disease are rare, and only a small nwnbt'r of patients
Adverse Effects
INFWENZA PROPHYLAXIS
Jmantadinr (Synmeutll
rimantadinr (ALrnadinr)
osekamivir(Tamifluj
I.ouwmivi (Rtltnza)
Inhala~on;l
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"""'"
develop severe liver failure. Thus, HAY is normally considered an acute disease, having no significant chronic form .
This makes HAY very difft'rent from hepatitis B or C.
like aU forms of hepatitis, the best trea tment for HAY is
prevention. HAY vaccine (Havri:l:, YAQTA) has been available since 1995. It is indicated for children living in communities or states with high infection rates, travelers to
countries with high HAY infection rates, men who have sex
with men, and illegal drug ust'rs. \Vhen a boostt'r is given 6
to 12 months after the initial dose, close to 100% immunity
is obtained. The average length of protection is appro:umatel), 5 to 8 years, although protection may last 20 years or
longer in some patients. Tht' availability of the HAY vaccint'
has led to a dramatic drop in the rate of this infection in the
United States.
Prophyla:us or postexposure treatment for a patient recently exposed to HAY includes hepatitis A inununoglobulins (HAIg), a concentrated solution of antibodies. HAIg is
administered as prophylaxis for patients traveling to endemic areas and to dose personal contacts of infected patients to prevent transmission of the virus. A single 1M dose
of HAlg can provide passive protection and prophyla..us for
about 3 months. It is estimated that the immunoglobulins
are 85% effective at preventing HAY in patients exposed to
the virus.
Therapy for acute HAY infection is symptomatic. No specific drugs are indiClted; in otht'rwise healthy adults, the infection is self-limiting.
HEPATITISB
Hepatitis B virus (HBY) in the United States is transmitted
printmily through e."(posure to contaminated blood and bod)'
fluids. Major risk factors for HBY infection include injected
drug abuse, sex with an HBY-infected partner, and sex between men. Health Clre workers are at risk because of accidental aposure to HBY-contaminated needles or body fluids. In
many regions of the world, the primary mode of transmission
of HBY is by the perinatal route and from child to child.
Treatment of acute HBY infection is symptomatic, because no specific tht'rap), is available. Ninety percent of
acute HBV infections resolve with complete recovery and do
not progress to chronic disease. lifelong immunity to HBY
is usuall), acquired following resolution of the infection.
Symptomsof chronic HBY may develop as long as ]0 ~rs
following exposure. HBY has a much greater probability of
progression to chronic hepatitis and a greater mortality rate
than does HAY. The final stage of the infection is hepatic cirrhosis. In addition, chronic HBV infections are associated
with an increased risk of hepatocellular carcinoma.
As with HAY, tht' best treatment for HBY infection is
prevention through inununization. Traditionally, HBY vaccine (Recombivax HB, Engerix-B ) has been indiClted for
health care workers and others routinely exposed to blood
and body fluids. However, universal vaccination of all children is now recommended, and some states require HBV
vaccination prior to entr), into school. Three doses of the
vaccine provide up to 90% of patients with protection
against HBV following exposure to the virus. A combina-
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54 1
542
UnitS
Rouleand
Adverse Effects
INTERFERONS
alriUJia,dDrI!ta
M~
throrrbxytoprnia,wicid!:
id!:at"OII
NONINTERFERONS;COMBINATIONS
1'0; 10 mglday
ffittc.lVr (BariWdt)
n<mldimJrOOOCPl (1omirudl"l/!J
tttiwdine (T)'lK.JJ
wrsions require only one dose per week. The PEG molecule
is inert and does not influence antiviral 3l:tivity. Additional
information on interferons used for other indications may be
found in chapter 3200.
Asse ssment
Bilst lin e asessmrnt prior to administration:
Undrotand t~ rtillOn t~ drug hi! bffir pr&ribtd in order to aslfS:i for
therapeutic tffem.
Obtiin a tomplete health hillory indudi fIIj immuniLIticrn, Il'spiratory.
neurologic, htpatic: or Il'nal d~iI~,ilnd t~ possibility of Pll'9nilncy.Obtlin
,drug history indudifllj alltl9~s,intk.odifllj spedfK rN(tions to drugs,
(Ul!ffit pmtription ,nd OlC drugs, hmlal p~rations,and akohol UI~.lk
to possiblt drug intffiKtions.
AsIfS:i ~gns and symptoms of tUIll'M infection noting on~~duration,
dWri{\frinks,.nd prtSl'II(tor .bmKe offewor or pain.
Enwtt ,ppropriate laboratory findings (e.g., CB( ~patic: ,nd rmal
function lIudies, firal tulrures).
,It"
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Tht~t~mwt
ExperitrKt ItImJPtUIic tffb (e.g.diministlf'il 01 ~ of sigm 1M symptoms ofinitdion,/II:IIf to mlintain rUrition 1M h)dRtion).
~!rl't' from,OIflptMnu' minillW~ iCIftrw tfftru.
Vt!b.llizt in undtrmnclirlg of tlltdrug's 1M, iltmse tftects, Ind ~ preuutions.
DmIonslrille proprr ~-Idministratioo of tilt medil<ltion (e.g.,~ timing, when kl notify proUr).
Implementatio n
Interven tio ns and (Ratio nal es)
Turn tht INtitm III not <iw:0II00U!' drug rtqimtn whtn~1ing bette(
on! to uke the fill (oolltof mecflUtioll.
[Moorq ilCItqullf nutrition, ~t..nd ~ IfflIs as impmtrnent is
Mol
ImlJu(t the p,ltitnt on the Iftd for ptrildc: lab work,(orrNting illIJ
symptoms we tfw, nml for pcruiblt Lib! (e.g., iKrNsf'd brui5ing or
bIetodingl.
Continue III monitor for heopni( and _tOJkitit!.. (HepatM; ilnd fl'1IiII
tolic~itl trIoIyour Ind ~ frtqutfll mOfl~OIing 10 prmnt ~
rfttm.lnuming Auid ifIIakt mlY pfl'Wllt drug aCl:lrmuiltion in kiclnfrs.)
--.
Monitorforsigns.lndsymptomsofblooddrwasi.u,f.~blttding,~
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544
Tfaoc:hthe pillient idtqwtf inftction conlrol and hygiffit mfi 5UrH 5U(h as
frtqUtnl hind washing. appropriat~ di~1 of dll'ssing material. and
arltqwte nutrition and 16t.~specially if CUITtll!ly immuMCOmpmmisNi.
The pillient mI)' nerd to lit isolated illmpitilorft'lThlin it homeduring pNk
traflllllis!ion ptriods, lemng to IOriaI isolation. AscmJin if the pilUtnl hu
Nistancf Milabit if a proIorged pmoo ofhomebuld stalUS isim~lm
Tfaoc:h the pillienllo practKf abstinence or to 1M barrier protfdion during
~I oKtivity mil if gtnital ~ionlarf 001 pres~nt.Gfnital HSV infruions
may bf traosmitted eY!'n in Ihf i symptomatK period.HaI'!' the patient
oomuk with their heakh !arf proYidfr aboot 5Uppres~ve therap)'.
Tfaoc:h the pillienl on oral aoc:ydovirto incl"f~ oral imake prior to LIking
oral aq<loYir and inclNlI' fluids to II pfrday thfOl.l9hoot therapy.
The piltienl, fami~,or(aR'giY!'r should lItabie to stlte the INIOn for the
drug; .ppropr;.tedole .nd "'lfduling;wh" .dvt". fffMU to obr.rve for
ilnd when to I"fport;and lhf amKipated length of medKition therapy.
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36.2
HN targets the T4lymph ocyte, using reverse transcrip tase to ntake viral DNA. The result is gradual destruction
of the immunf system.
36.3
16.4
Drugs from !lYe drug classes are used In various combinations in tbe pharmacotberapy of Hl Y-AlDS. The nucleotide reverse tranS(:riptas<> inhibitors and th... fusion
Inhibitors hnve retently befn dlS(:overed.
36.1
36.&
36.S
Tbe reverse transcript ase inhibitors block HIV replica tion at the level of the rewrse transcrlptase enzyme.
Th~ include the NRTIs.. NNRTls, and the NtRTIs.
36.9
16.6
tion. Newer drugs for HBV and liBC have led to thera
pies for chronic hepatitis.
popu1ation."
The nurse und erstands thai the laboratory tests th~t must
be a5&.'!iSed. while a p~tient is on drug thenpy for HIVAIDS ~re: (Selt'('t aU that apply.)
I . Csc.
2. clotting factors..
3. HIVRNA.
4. CD4lymphocyte count.
5. BUN.
When providing patient and famUy education for the
nucleoside reverM' trnnscriptase inhibitor drugs for
HIV.AIDS, the nurse would teU the patient to take the
medication:
I. on an empty stomach.
2. on a full stomach.
3. with apple juice 10 decrease the taste.
4. with orange juke 10 increase absorption.
A patient is concerned about contracting influenza.
The
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....
",,"
546
Unit, Thl'tmmu""sym'm
EXPLORE
~.-----,
alld
Prepale
101 SlJCC8SS
www.""".....
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DRUGS AT A GLANCE
LEARNING OUTCOMES
AlKYLATI NGAGENTS
plllJr551
pi1J' 556
Nitrosoureas I""Fm
1.
2.
3.
ANTIMETABOLITES p11l1,,5J
FoHcAdd Antagonists p m
fII11' 557
4.
5.
PyrimldineAnal ogs
PurineAnalogs
fIIlIJ'm
1'11'1<'555
Explain the significance of growth fraction and the cell cycle to the
success of chemotherapy.
10.
(~ mptothed ns p 559
fIIlIJ' 559
f1l1"56IJ
Q rall10xjfen
paJt554
GlurocortkoldslCortkosterolds
D".cri~
cancer.
ANTITUMOR ANTIBIOTICS
paJt 56IJ
11 . Use the nursing process to care for patients who are receiving
antineoplastic medications as part of t heir t reat ment of cancer.
paJt 56]
paJt56 1
KEYTERMS
adjUYilnt memoth<Ipy
plJ/}r55(J
. Ikyl.l i ln paJtm
alopfdil p<q m
aromatas. inhibitor
pajI' 561
{amptothfdn f1XJd59
can{l'Ifm linomii fJI1J' >I/J
dlemotherapy
jlIlIJd 49
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ta .. M 1'"'1"" 9
topoilomeril.1 fIIlIJ' 559
S48
UIIIIS
B_ _ r
u..g ....
."
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some cases, the site of the cancer may be distant from the entry location, as with bladder canar caused by the inhalation
of certain industrial chemkals. Some known chemical carcinogens are listed in Table 37.2.
A nwnbl'l' of physical factors are alw associated with cancer. For example, exposure to largl' amounts ofx.rays is as50Cialed with a higher risk of leukemia. Ultraviolet (LN)
light from the sun is a known ClIw;eof skin ca ncer.
It is estimated that vlr~ are aSiOCiated with about t5%
of all human cancen. Examples include hl'rpes simplex
types I and II , Epstein-Barr. human papillomavirus (HPV).
cytomegalovirus, and human T-Iymphotrophic viruses.
Factors that suppress the irrunune system, such as HIV or
drugs given after transplant surgery, may encourage the
growth of cancer cells.
PHARMFACTS
Canal!r
It is n~ttd!!wot _!!won 1,400,000 lIN Ci/lCrf (ISH oaur ~h
I'N~ with _!halt Wi,OOO de.tta (~ l.soo ,",*00 lily).
.,.1<
Description
Examples
BffiilJl tumor
Adtoomi.~lilloma and
Cardnoma
Call(~of tpithtlial
lpom.1,olleoma,mmingioma
LN:emia
CaIl(~oftlM'
Lymphomo
.,-
Call(~oflymphoid
Mali9:lant tumor
mlUf
...-..
.Agent
"...,
T'ypeofcancel
""'
lPuhmi
Hoti
lungandlkin
luog;hudarodoM
Vin)'ldl~
""'
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Malignant mtlallOllla
OII~nk wltoma,fiblOlarmrno, Kapoli's WUomi,
Djosarmma
550
UnitS Thl'lmmuneSystem
blood-brain barrier to reach brain tumors. Others are instilled directly into body cavities such as the urinary bladder
to bring the highest dose possible to the cancer cells without
producing systemic adverse effects. Otemotherapy has three
general goals: cure, control, or palliation.
When diagnosed with cancer, the primary goal desired by
most patients is to achieve a complete cure; permanent removal of all cancer cells from the body. The possibility for
cure is much greater if a cancer is identified and treated in
its early stages, when the tumor is small and localized to a
well-defined region. Indeed, the 5-year survival rates for
nearly all Iype' of cancer hali increa,ed in Ihe palil two
decades due 10 improved detection and more effective therapies. Examples in which chemotherapy has been used successfully as curative treatments include Hodgkin's
lymphoma, certain leukemias, and choriocarcinoma.
\'/hen cancer has progressed and cure is not possible, a
second goal of chemotherapy is to oontrol or manage the
disease. Although the cancer is not eliminated, preventing
the growth and spread of the tumor may extend the patient's
life. Essentially, the cancer is managed as a chronic disease,
such as hypertension or diabetes.
In its advanced stages, cure or control of the cancer may not
be achievable. For these patients, chemotherapy is used as
palliation. Chemotherapy drugs are administered to reduce the
size of the tumor, easing the severity of pain and other tumor
symptoms, thus improving the quality of life. Examples of
advanced cancen; for which palliation is frequently used indude osteosarcoma, pancreatic cancer, and Kaposi's sarcoma.
O!.emotherapy may be used alone or in oombination with
other treatment modalities such as surgeryor radiation ther-
o Bleomycin
o ElDpDSjde
o Paditaxel
Teloph......
II.
, ,,
I MITOSIS I
,"
\
#
Non~Jl"Cffic
ID
phesa 01 cell cycle
o
o
AIkyieling egents
Anlitumot anlibiolics
~.""
,'.'.'
'.'
Anaphase
. "~
o HotmOOII inhibitofS
~
FlgureJ7.2
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-- .
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55 1
tially cause the tumor to return and kill the patient. The relationship between cell kill and chemotherapy is shown in
.. Figure 37.3.
It is likely that no antineoplastic drug (or combination of
drug;) will kill 100% of the twnorcells. The large burden of
canc.r cells, however, nt"}' be lowered sufficiently to permit
the patient's immune system to control or eliminate the remaining cancer cells. Because the immune system is able to
eliminate only a relatively small number of cancer cells, it is
imperative that as many cancerous cells as possible b~ eliminatoo during treatment. This example reinforces the need
to diagnose and treat tumors at an early stage when the
number of cancer cells is smaller.
Primary tumor
1,0(0,000,000 cells
Reduced tumor
99'1'. kill
10,000.000 ""Is
Ao<Iuoed tumor
99.9'1'. kill
1.000,000 cells
T "" Ia
''''''''''ng
remaining
cancer cells
.. Figure 37J Cell kill and chemotherapy
552
UnIIS
TABLE 37.3
Blood ToxicIty
AnmU(lDwlfdbloocl (fII(M{1
llI*aprnilwiltlltlOptl'lM (kIwwhft blood 1 __ )
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CIIopltll1
37.8 Classification
of Antineoplastic Drugs
Drugs used in caI"Kef chemotherapy co me from di,et"se pharmacologic and crn-mica! classes. Antineoplastics have been
extracted from plants and bacteria, ~s well as created entirely
in the laboratory. Some of the drug classes attack ceUular
macromolecules, such as DNA and proteins. whereas others
poison vital mt'"labolic pathways of rapidly growingceUs. The
common theme among all the antineoplastic agents is that
they kill or at least stop the growth of cancer cells.
Classification of the vanoU5 anhneopla stl cs IS quite vanablt'" because some of these drugs kill cancer ceUs by several
difft'"rellt mechanisms and have characteristics from more
than ont'" class. Furthermore. trn- medlanisms by which
some antinooplastics act ~re not rompletely understood. A
simplt'" method of dassifying this romplex group of dru gs
includes tht'" following six ca tegories:
LibraryPirate
DruglforNeoplal.la
55 3
. Alkyl.ating agents
Antimetabolites
Antitumor antibiotics
Honnones and hormone antagonists
Na tural products
Biologk respornt'" modifit'"rs and monoclonal
antibodies
Miscellaneous antineoplastk drugs
ALKYLATING AGENTS
The rlnt alkylating agents, the nitrogen musta rds, were d eveloped in secrecy as chemkal warfare agents du r ing
World War II. Although tht'" drugs in this dass have quite
different cht'"mical structur<'"S, all sha re the co mmon characte r istic of forming bonds Of linbges with DNA, a
process called alkylition. ~ Figure 37.4 illustrates the process
of alkylation.
37.9 Pharmacotherapy
with Alkylating Agents
Alkylation changes t~ shape of the DNA double helix and
prevents tht'" nucleic acid from rompleting normal ceU divi.ion. E"ch :ill<ytating agent allaches to DNA in a difft'"rent
manner; howt'"ver, ooUecti vl'iytrn- alkylating agents have the
t'"ffed of inducing cell death, o r at le~st slowing t~ replication o f tumor ct'"Us. Al though the process of alkylation occurs indt'"pt'"ndt'"ntly of the.:ell cycle, the killing action does
nol occur until the affected ( ell allempts to divide. The alleylating agents havt'" a broad spe<:uum and ate used ag~inst
many types of II\OIlignandes. They are some of the most
widely prescribed antineopla'llic drugs. These agents are
listed in Tablt'" 37.4.
Blood cells are panicularly st'"nsitive to alkylating agents,
and bone marrow suppression is the primary dose-limiting
adverseeffed of drugs in thi s d ass. Within(];lys after administr:ation, the numbers of erythrocytes, leukocytes, and
platelets begin to declint', reaching a nadir at 6 to 10 days.
Epitht'"lial cells lining the G I tr~" are also (];Imaged, r<'"S ulting in nausea, vomiting, and diarrhu. Alopeci~ is expected
from most of the alkylating agt'"nl5. The nitrosoureas and
mechlorethamint'" are strong vesicants. Appro.'timately 5%
of the patients trt'"att'"d with alkylating agents develop acute
nonlymphocytic leukemia 4 years or more after chemotherapy has been completed.
ANTI METABOLITES
Antimetabolites art'" antineoplastic drugs lhat chemically reM'mble essential building blocks of ceUs. These drugs interferewith aspects of the nutrien l or nudeic add metabol ism
of rapid ly growing tumor cel ls.
SS4
K-".a:--l
~
...
o"
Alkyla.ting ItQOOI
37.10 Pharmacotherapy
with Antimetabolites
Rapidly growing cancer cells require large quantities of
nutrients to construct cellular proteins and nucleic acids.
Antimetabolite drugs are structurally similar to these nutrients, but they do not perform the same functions as
their natuml counterparts. When cancer cells attempt to
synthesize proteins, RNA. or DNA using the antimetabolites, metabolic pathways are disrupted and the cancer
cells die or their growth is slowed. The three classes of antimetabolites are the folic acid analogs, the purine
analogs, and the pyrimidine analogs. These agents are
prescribed for leukemias and solid tumors and are listed
in Table 37.5.
The purine and pyrimidine analogs are structuraUysimilar to the natural building blocks of DNA and RNA. For ex ample, the pyrimidine analog fluorouracil (5-FU, Adrucil,
Came, Efudex) is able to block the formation of thymidylate, an essential chemical needed to make DNA, and is used
in treating various solid tumors. After becoming activated
and incorporated into DNA. cytarabine (Cytosar, Cytosine
LibraryPirate
ANTITUMOR ANTIBIOTICS
Antitumor antibiotics are drugs obtained from bacteria that
have the ability to kill cancer cells. Although not widely
used, therare very effective against certain tumors. The antitwnor antibiotics are listed in Table 37.6.
Drug
Adwrse Effects
NITROGEN MUSTARDS
bmdamllltillt (Trt.nda)
Ntma, Kmiring,~riris,.~rash,
cNoramllWl (INmn)
PO; InitiiII dose 1-S mg/doly; Malnttnanct clost; I- SlIIg/kg t'VflY 7- 10 ~)'S
tUnmuUinr (ErBcytl
ifOlfDide (!fee)
rMhloftth.imillt (Mu5UI'gIm)
1Y;611lCJ11111on~ 1 ind8c1i18-di1ycydt
mtlph.liln (Alman)
PO;6mg/diyfor 2- 1wk
anaplryltrkl nmhl!!!oxidty
NITROSOUREAS
afmllSlint (BiCHU,GIacStI)
1Y;1OOmg/rrtlMrY'wk
Iomustilt (CtrHU,(CNU)
urtptozOOn (ZaIlO5al)
buitJfan (Myltfilll)
PO;(-8 mglday
Qmopatin (P;wipla~n)
cispQtin ( ~tinol)
1Y;20mg/mi/daylor 5 ~
oxalipla~n
(8oxatiftJ
proGIrb.izillt (ManjaM)
IemOzoionide (lemodir)
IY;OJ~AmgJkgMry
TABLE175 ~
I..... wk
Antlmetabolites
Drug
Adverse Effe<ts
ptnIttrtud (Allmu )
praialrt:late (Fdot)'n)
PYRIMIDINE ANALOGS
Qptdtibint (Xtb:Ll)
Ilfpot.(~)
ftoxwidine (ruDR)
ftUOl'OI,I'~U
(Sru,Ad'ud,(.arac, Ehde!)
gmcitabine (Gtrnz,JrJ
PURINE ANALOGS
c1mblM (ltustatin)
cIofalabint (OoLII)
ftudarabile (Fludal'i)
ptnlOSlatin (H~nt)
PO; 2 m4fkghlay
PO; B mglkgfday
IIQria incicatt common idl'l'Bf tfferu; unOO1ining imkates strious acIYme effKtl.
LibraryPirate
SS6
I Cyclophosphamide (Cytoxan)
ADVERSE EFFECTS
,
iIi
ADMINISTRATION ALERTS
oc:ruB during days 9-1 4 of therapy; the patitm is at dangelOlH rille for !I'\'frt'
PHARMACOKINETICS (PO)
Unmnwn
IINk:l h
OnV'!:
Halflif!: H l h
,-,'C'C
'fuC
" :IO
C":: !..CI~:L-:-C\':'_______________./
Normal mlltabolile
0
0
,-<X'>
H,N A
Folic acid
N ......
GUlln;""
Antimet.bot~.
"'
",:X',>
,,,J...,
Melholra x.ate
~
Thioguan ....
LibraryPirate
"
"":J
oJ...,
,I
U-acil
o"J..,~'
,
Auorouradl
Mttoot~ute
is ,n ,ntimrubolitt iIV,ibble by tht or.Jl p'~nter.ll. ,nd intratheul routH. By blockilg the S)'Ilthtlis of folic acid (vitimin BJ, mttootl6itt inhibiu replication, partirubrly in rapidl)o dividing (tlls.1t is pR'ICrilltd aloot
or in oombinuion with othtr d~ for ChorOOKinooy, o;ttogeni( san:oma,
IeukemioH, head and otdulKtB,brtmun:inoma,and lung CiKinoma.ln iddition to its role as in ant"metabolite, metoot~l:IIte hil poWl'rlul immunOlUppll'ssant thit "n lit Ulfdto t~it!n'M' rhtum,toid arthritis,uktr.Jlivt colitis,
upus,and psoriasis that OR unrt'lpOM~ to wfer lII!'dications.
ADMINISTRATION ALERTS
Avoid !kin HpOIU~ todrug.
INTERACTIONS
Dru;Hrug: 800e mallow wppressaoBsuth ~~;qon1l or radiMn
the!apyma, UUII' ioofNd IIIett!; th! patil>nt will ~fI alawn dol>! of
~_f. (orKIIJfI"l UIf wiII1 HS.IJ[Io; may INd to Ift'fIf IIIIIhoIrmtf toliOt~
.l.lpiin IOiY interl~wiII1 omtioo of ~lIitt,lHdi09to incrNIfd 1>1'1"l1li
IM>ilaed llIlKity.CoooI"rootadminiltration with ivl'orai iJ((inI may ~ i1
dKrufd antibody fflpoI1lf DI incrNIfd idWllf rations to th! Q(OO!.
PHARMACOKINETICS
Onstt: Variable
P!ak: 1--4 hPO;O.5-l hIMlIV
Halflif!: 1--4 h
Duration: Unknown
Ll b Ti5U: S!rum uric: Kid levels may i1UMI'.1!Iood ~ <DII"tI wil iiminilh Ib to
bone IIIIIfOW wppreslion.
HerbaHood: Food ~ !ho">ool iblption of ~lII1f.&:hioacN IIIiI'f
irK_ th! rille ofhtpatot~xitity.
dalllOlUbidn (Ctrubidot)
~n(81tnte)
idanDdn(ldamydn)
mitanydn (Mutimyan)
LibraryPirate
~nglt dose
"
55 8
37.11 Pharmacotherapy
with Antitumor Antibiotics
A number of substances isolated from microorganisms have
been found to pos.ser.s antitumor properties. These chemicals are more cytotoxic than traditional antibiotics, and
their use is limited to treating a few specific types of cancer.
For example, the only indication for idarubicin (Idamycin)
is acute myelogenous leukemia. Breast carcinoma is the only
approved use for epirubicin (Ellence).
The antitumor antibiotics bind to DNA and affect its
function by a mechanism similar to that of the alkylating
agents. Thus, their general actions and side effects are similar to those of the alkylating agents. Unlike the alkylating
agents, however, all the antitumor antibiotics must be ad
ministered intravenously or through direct instillation via a
catheter into a body cavity.
As with other antineoplastics, a major dose-limiting adverse effect of drugs in this clar.s is bone marrowsuppression.
NATURAL PRODUCTS
(PLANT EXTRACTS AND ALKALOIDS)
Plants have been a valuable source for antineoplastic drugs.
These natural products act by preventing the division of
cancer cells.
37.12 Pharmacotherapy
with Natural Products
Agents with antineoplastic activity have been isolated from
a number of plants, including the common periwinkle
I Doxorubicin (Adrlamycm)
ADVERSE EFFECTS
TIll> man ~ clost-limiting adm~ tffed of doJ:Olllbicin is rardiotOllicity.
,\artt ~m inrkidt dysrhythmias; dtlayed tffrcts mly indudt in~rsiblt
IItln failu~.likf man, of tht .Jntiunrt r drugs, doJ:orubicin may profoundly
Iowfr blood (tll (ounts. Acut~ naU~J .Jnd vomiting a~ (ommon and oftt n ~
qui~ Jntiemttir therapy. Com~, though rf"lersiblt, hair Ion occurs in most
pat~rru.~ondary maligllan(ifi,ept<iJl~ JMt myflogtnous Itukemia, mly
occur 1- 3 )'I'ars following therapy.
(ontraindi(ations: Domnrbic:in is (ontraindicated in patienl> who J~ imlIlIoosuppresed orwho haw ~nsitivityto tlltdrug.
INTERACTIONS
I)ug-l)ug: If digoxin ~ lakin (OIKUlI!ntly,paliI>n( Il'IIImt5goxin Ir>v/'kwil
~.lMwith ~I may INdio im.MI plalmadNooa> of
ihona:i1 and deuMfd effO'ajy~s.lIItwith p/Ii'Il)1oil may iNdtodeuMfd
ph@nytoillffll, and possi~e seizin ar:tjy~y. Hepat~1llIIirity may amI" ff
mtlGlpIOpOm. ~ "ton <OO( ..... tIy.tktwith ..........1""I' ioawoo .......
ihona:i1 "''/ek,INd~ to ooxolloon toxidty.
Lab T151>: )frum uric: idd JfId illpMlite aminotm\llJR lAS n ""'eIs may
inmast.8iood<ell (ounl> wil diminilh due to boor> marrow IlWrI'iion.
IIerbaVFo!XI: rmn IN JIIoIYfnl\alKf thtMltitllnor tMlyof wlOll.tim~
IIns woo IN1 dKrNIe the etlKtiveness of ikD:lfltlir:i1.
TINlment of ()rrdo~: The primary r=k of doJ:orubic:in O"/trdosagt iI imlIlIoosuppresion. Tl"Ntmerlt indudts prophylactic antimicrobials, plateIM
mnsfusions, symptomatic Utiltllll'nt of lIIKositis,.Jnd possibly IItmopoietic:
growth f.J(\or(G'(sF. (".',I.(SF).
Rtftr III MyMIsJrIgKI fDf Q MnInq PreIS fooIl spffiIt IIIIM ItrJ9.
PHARMACOKINETICS
Onsd: Rapid
Peak:Unknown
Halflife: 17- 32 h
Duration: Unknown
LibraryPirate
'1101'1,,37 Drugs(D<f\IeopLHIa
"n"
VINCA ALKALOIDS
"tintUstint(Vdl~n)
lV;l7- 18.>mglm'~
Q Iinainile(OIKO'!'inj
"tinorelbint IN.rlelbintJ
lwk
TAXANES
mtaRl(laxOiert )
paditaxti (Taml)
1 1V;60-100mglm'MlYlwk
IV; 1l5- 175 mglm' MIY 1 wk
TOPOISOMERASE INHIBITORS
60p0sid!, (Ve~sid)
irinolKiin (Camplosar)
lerIiposide (Vumon)
topoll'(.Jn (1Iyum~n)
LibraryPirate
559
Adverse Effects
560
UnitS Thl'lmmu""Syst""'
I Vincristine (Oncovm)
ADVERSE EFFECTS
lhr most Irrious dose-limiting adYl'~ effects of in{mtilll' relate to ner\OUl
S)'ltffll toxicity. Children all' partirularty IUI(~ptilR. Symptoms include 111mb111'11 and tingling in the limb~ mUl{Ular ~akn!"ll, IoSI of neuralll'flrm, and
p,in. StYerr mnstipation is com man and paralytic ileus lIYy lXtur in young childlt'll.Rt'YI'fSiblr alopecia OCQJrs in most patients.
Contraindi{a\jons: Vincristine is (omraindica~ during pl!gnalK)' and lactation. Caution should II!' used whrn til'uing patients with hrp.atic im piinnent or
obstnJctiYl' jaundice.
ADMINISTRATION ALERTS
Extransation may r=k in Ifrious tissur da~. Stop injtction imrnedi-
~tely
PHAR MACOKINET1CS
Onlet: Unknown
Peak: Unknown
Halflifr:ll1- m h
Durat ion: 7ct.ys
found to exhibit antitwnor activity. The mechanism ofhormone antineoplastic activity is largely unknown. It is likely,
however, that these antitumor properties are independent of
their normal hormone mechanisms because the doses uti
lized in cancer chemotherapy are magnitudes larger than
the amount normally present in the body. Onl), the antitu mor properties of these hormones are diKussed in this section; for other indications and actions, the student should
refer to other chapters in this text. The a ntirumor hormones
and hormone antagonists ~re listed in Table 37.8.
In general, the hormones and hormone antagonists act by
blocking substances essential for tumor growth. Because
these agents are not cytotoxic, they produce few of the debilitating adverse effects seen with other antineoplastics.
They can, however, produce significant adverse effects when
given at high doses for prolonged periods. Because they
rarel), produce cancer cures when used singly, these agents
are normally given for palliation.
GlUCOCORTICOIDS (CORTICOSTEROIDS)
The primary glucocorticoids used in chemotherapy are dex amethasone and prednisone (Deltasone, others ). Because of
the natural abilityof glucocortiooids to suppress cell division
in l),mphocytes, the principal value of these agents is in the
treatment of lymphomas, Hodgkin's disease, and leukemias.
They are sometimes given as adjuncts to chemotherapy to
LibraryPirate
INTERACTIONS
GONADAL HORMONES
Gonadal hormones are used to treat twnors that oontain
specific hormone receptors. Two androgens, fluoxymesterone (Halotestin) and testolactone (TesIac), are used for
palliative therapy for advanced breast cancer in postmenopausal women. The estrogens ethinyl estradiol and diethylstilbestrol (DES) are used to treat metastatic breast
cancer and prostate cancer. The progestins medroxyprogesterone and megestrol (Megace) are used to treat advanced
endometrial cancer. Leuprolide (Lupron ) is similar to gonadotropin releasing hormone (GnRH ), and is used for advanced prostate cancer when other therapies have failed.AIso
similar to GnRH is histrelin (Vantas), a drug approved in
2006. Approved for advanced prostate cancer, histrelin is an
implant that is inserted subcutaneousl),in the ilUler aspect of
the upper arm to release the hormone over 12 months.
ANTI ESTROGENS
The anti estrogens are used to treat tumors that are dependent on estrogen for their growth. Tamoxifen (Soltamox),
'1101'1,,37 Drug'(D<f\IeopLHIa
561
Adverse effects
dwmmlOlll'jDeudron.oIhtrs)
PO;O.lS bid-qid
ditlhyl!l~bt!lrolID(s. S1il>tmol)
We'qllrgoifl,momflio.abdJmif"IQl
di5lflHion.lwtllrl'f14 ftIlhif14 dQrrlIeG.
""'9
HORMONES
ftuoxyJllffimHll' jH alot~!lin)
PO;10mgtid
1M;400-1.OOlmgql wk
(w~
1Iffi1lU~ ~masri4liflUlijm
(ItlflmtrOlII',ltIlo/Q(/Ontj
!mOO1
~roIjM~lt)
PO;lO- I00mglm'l~y
testolinOlll'(T~)
PO;l,Omgqid
HORMONE ANTAGONISTS
anastrorok(Arimid9j
PO;1 mglday
bitJlutamitk I~x)
dt9amix (Firmaqon)
PO;50lII9Iday
StD:Ulilll'OUl; 240 mgloadilg doll' followtd Il)' 80 mg "~
Qffhtnio.l!QUJfQ
l/ol~imm1lW..brfl)ff
UtmtstiUIt (Aroma~n)
18""
PO;2, Ill9lday ift... a IMal
ftutamitk (Eulain)
PO;250mgtid
lulwstrint (fa~odtx)
1M;2S0mgooa
gostI'Hn (ZoIadtx)
hilt!!!in (Yantil)
ItUOlOit (Ftmara)
PO;2.SlIM}Iday
Subrutalll'OUlly; 1 mglday
Ibka!utimide.mr~rnl. htoalOuo:ility
(flularri4el !Utial dyllunnion (QOX!!in.
mo (501119)
niknami~ (tilincton)
raloxh (Evisti)
O timoxnen
ttmifmt(fareton)
triptorl'lin (TmstI)
LibraryPirate
mo~".in,hnld<Kht,dkJ""",.
ANDROGEN ANTAGONISTS
Hormone inhibitors also include the antiandrogens bicalutamide (Casodex), nilutamide (Nilandron). and flutamide
(Eulexin). These agents are prescribed for advanced prostate
cancer. which is strongly dependent on androgens for growth.
S62
UnitS Thl'lmmu""Syst""'
L IFESPAN CONSIDERATIONS
-
37.14 Pharmacotherapy
with Biologic Response Modifiers,
Immune Therapies, and
Miscellaneous Antineoplastics
Biologic response modifiers and inununt' therapies are med"
ications that stimulate tht' body's immune system to rid the
body of tumor cells. The immWlOstimuiants are less toxic than
most other classes of antinooplastics. These agents, along with
somt' miscellaneous antineoplastics, are listed in Table 37.9.
Types of drugs within thissubdass include the following:
e Interferons: Natural proteins produced byT cells in
response to viral infection and other biologic stimuli.
Interferons bind to specific rect'ptors on CllnCer cell
membranes and suppress ct'll division, enhance the
phagocytic activity of macrophages, and promote the
cytotoxic activity ofT lymphocytes. Peginterferon alfa2a ( Pegasys) and interferon alfa-2b (Intron-A) are
approved to treat hairy cell leukemia, chronic
I Tamoxlfen
ADVERSE EFFECTS
Timouit>n is an oral anliestrogen thit is i ptmrred drug for tR'aring mewtatic blNlt UIK('I.1t is effliYr igainn brun tumor crils that requiR' estrogen
for thrir glOWlh, which a~ known as ~trogen receptor ([HI POlitivr {~Ik.1t
bloch estrogen fl'U'pton on brean u nm (elk, but tamOlifro actually twilles
~trogen l"t{eptoB in other pam 01 thr body, r~ulting in t)'piul ~trogtn-like
effects!UCh al rrduU'd IDllrv~b Jnd ilKrralfd mineral den!ity 01 bo~.
Auniqut futu~ 01 tamoxifu is that it is the only antineoplastic thit is ap.
p<OKi for prophyl.. is of bR'iI' UII('~ for high.ri<k pnirnu who Olf II riskof
drYrIoping thr dill'~.ln lridition, it is approved as adjunaiYr therapy in
women following lIY5If{tomy todrm~ the potemial foruncerin throppositt brtill
Othrr than n"UIN and vomiting, tamoxifen prodU{~ rmie serious toxicity. Of
colI(em,howeYl'l,is theassoci.Jtion of tamOliit>n thtrapy with an inausKI risk
of endometrial (alKrr and thromboembolic dile<llr, induding strokes and pul
morw ry emboli. Hot lias hr~ !krid ~~ nlion, j nd vagini Idischjrgei i It relatiW'ly
common. TamOlifen uu~ initial "tumor liaR'"- an idiosyncratic ilKrfill~ in
rumor~, but this is an l'lpKtKl thrrapwtic M'n1. Hyptrtenlion and KlemJ
ocarr in lbout 1('% 01 patient> taking tilt drug
Can lr"; ndi<dlion>: (olll,.iooo..l"" 10 lilt u,", of 14,oolil. " in<.lude . n1ic.oagulant therapy, prMJiliing mdomnrial hyprrpl.lIia, history of thromboem
boIi! diINle, p~nancy, "nd lactation. Prrautionl shoold lit ob!l'lVfd in
p"tirnt; with blood dilordtB, ~I dilrurbanU'S, utJract~ hyprrukrmia,
Jnd hypen:oolrslrrolrmia.
ADMINISTRATION ALERTS
Unknown
Peak: 3~h
Halflift': 7c1a~
Duration: Unknown
LibraryPirate
INTERACTIONS
IlerbaVForxl: Unknown
Trmtment of ImrdOlf: Stizurrs, neurotoxicity, and dysrhythmial
with OYI'rdo~. The patient is tR'aifd s)'Illptomatiuliy.
IIt/i>r 111 MyMnIngR fot ~ MnJrIg 1'rf'55 Foon lpK/It 1II1M atJg.
rna)'
our
(1101'10137 Drug,fD<Neopla,"
~108t'nous leukemia, Kapsoi's sarcoma, and chronic
hepatitis B or C
. lnterleukin-2: Activates cytotoxic T lymphocytes and
promotes other actions of the immune response.
Marketed as aldesleukin (Proleukin ). this drug is
indicated for metastatic rena] cell carcinoma.
563
Adverw Effects
a~rtlalliflt(Hwlm)
1'0;65 mglrn'/day
a~ triolid! (TrisfflJI)
~raginalt (Ebpn)
bo:arot_ (lugretioJ
hydroxyull'ol (Hydr61)
1'O;20-lOmg/day
iote-fffllO.!Itr1 (RofI>roo-A.lotroo A)
(w ~ 454 for tilt Pltlloty]N' Drug
tm<X> 1
ilabtpilmt(lKffilpril)
1V;40mlJ/m'infllltdamlh"tf'! lwk
ImmilOk (Errjamisvl)
mitoufIt (l)'soho)
asparolginalt)
romidtpsil (lstodax)
'IOrinostit (loIinu)
IdMrooKJOO (1orneta)
1V;4 mglW~atlNlI15min
MONOCLONAL ANTIBODIES
aimtWlllloib (Camp.!th]
1V;3-lOIII9Iday
btYadzumab (Amlio)
bortnomib ('kk.Jdt)
wuxinab (&binD:)
e-\oIioib (TaKt'loI)
gefninib(rnsa)
1'0;150-500 Ill9lday
1V;911191m'for2h
1'O;400-600lII9Iday
p.!ZOp.!nib (Votriffit)
ritlilin.Jb(Ri!uun)
Ilinitinib (Suttnt)
sorafmib (Neuvir)
1'0;400 mg bid
tositumomab (Bt'Dir)
trutuzumib (IIffi:tplio)
LibraryPirate
56 4
UnitS
Thelmmull<'S),,'I'm
PHARMACOTHERAPY ILLUSTRATED
37.1 Monoclonal Antibodies and Cancer Cells
NOITTIIII cella 1\&.... no
IU"TIOI"-apec;fic antigena
of their auof...,....
tumor-apecific antig-ens.
The anliQ "" p,,,,,ent is
diff""",t for """" tYP" of
,~.
Adminis ter
.-
Adminis ter
MAB
MAB
I
. '"",,,,,
fixation, or induction of
apoptosia.
Exampln:
Rituzimab (Rituxan)
Alemtoromab (C~)
LibraryPirate
........'
Cetu>.imab (Erbitux)
T.... tuz:umab ~ptin)
565
Assessment
o
o
o
InlNtion
Activity IntolewKe
Fatigue
o Anxiety
ImNlanctd Nutrition,lffi Than Body Requill'menll
Der,dffit Fluid Volume
o Oiarrhea
o Impaill'd Oral MuWJS Membrann
o Impairrd Skin Integrity
o Pain (ac:uteol(hronic)
o Scx:ia llsolation
o lnelfectift Therapeutic: Rtgirnm Managernent (rtlated to (omplu
mtdication ll'9im~n and disNse trtatrnem)
o DerKitnt Knowltdge (Il'lattd to dilNlI' pl'Xn , and drug tooap)'l
o HoptIes!lltll
o SpiritlQlOistrrss
o Risk for D!'!:lNsed Cardiac: Output (rtbttd to ~dftlll'drug efftct
o Risk for Injury, Risk for Falls (rtbted to adverse drug ~ffe(l\ or dill'm)
o Risk for Call'gi!'r Role Strain
o
o
patient will:
upt"rir-rKt thera peul:ic tfffcts k g., Il'duction intumor flY" or dt (Il'.md progrnsion of abnormal cell growth, abll' IKt of signs i nd symptoms of (OlKUmnt
inlenion, able to maimain ADU).
Bf!lft from, or nperiflKt minima~ idv~1II' tffts.
o V~rbilizt an undfr>tanding ofthedrug's UII'"dvelll' ~1f1S, and rrqJill'd precautions.
o Demon!lrate proper seIf..administration 01 tilt medication (e.g.,doII', timing.. wht n to notify provider).
{Continued}
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566
UnitS ThelmmuoeSysum
--+-
o Continut to mon~or fIl'~nt lib work:(O( ANC, pllteict coun~ hepatic ind
ft'JI II fundion tests, eifclrolytes, gkK~, and urinalysis. (Bone marrow
supprtSsion with I!'IUking blood dysunias is an opKIed idYfrIf" effKl
and will be monitorrd b)' AOC,(BC, and plat~1tt counn.)
o Teach the patient 01 the need for Irtquf", lab work. HaY!! tilt patient ilifrt
I<tb pmonnelofchemotht r.lPY ust.
If pt"riphtral ninlate!lled for phlfbotomy, KJUpulous cifilnsing of the ~tt
prior to stide and prolongtd pressurt may be Il'lJIill'd If a c~tralline
C-_ _+-_.C'C~C'Cis used, Krupulous cicansing of the pon is rtqUirtd.
Pro~ antiemtlic: the"py during ~minist"tion of drugs with high and
morlmte mtlic potential. If the patient has had prmous tll'atment with
thecht mothtrapy rrl}imen,as\f"$s the fIIl'11t of naUlfllnd I'Omiting and
whkh intiemttjcr Iwd tht molt succm in prtI.'I"lting naultl.
o Encourilge incrr.std nuid inlilkt,up to II perday, taken in f.eqUl'llt vull
Jmounts.
Enrouragesmallhigh-<alorit, nutriem-denst meals rlthtr thin large,
inirrqUl'nt IlINls. Nutrition.1 su ppifmenn such iI SUtVury, Boos~ or En surt
l1'l/I'1 help boost Cilloric im!kt.
Awlid spicy, highly scented foodS,ind uctssmly hot or cold Ioodiduring
ptriods of naulta. Small ~ps of Cilrbonated ~rilgt~ !'Specially gingtr aif,
may provide ft'lief.1f GI efiKis predominatt (e.g, diarrhea), mid high
roughaqe foods.
o Encourage f.eqUl'llt oral h)'9~n t: rinSf mouth, tspecially abr tating; USf
lip balm;and 'l'Oid akoholb.~ moutliwdsh, ...mkh m be drying to Iht
mucosi.
Continut to ilS~S forthe PJl'ltnct of pain and pKlYide for adtquate ~in
medication./Pilin may I!'IUk from ~anced disNst or advtr\f"drug tIlKU.
In advanced disease, pain medication is not Withheld.ASSffi possible dl\Jl}"
related caUStS for ~ in and trell the UUIf ...men possibif.)
EnCOUr.lgf tht ~tient to Itek pain ll'Iil'fwiltn nffiled. Teach til!< patient,
family, and ull'9mr that abselKeof plin is a goal in tht tll'atment of
advanced disNse and pain medication should not be withheld.
PJO'I ie1e for ~ftjwte rtst.(Fatigut related to anemia Ind adY!!JIf drug
Teach the patient tht importalKe of s~dng daily routifll'l throughout the
tflKls is common,tspf(ially around the nadir and immediately after:
diy.Encouragt JI'It whtntvtr fatigutocrurs.
Fatigut may continut ifteHell (ouml ft'IUm to normal ilnd miy ptrmt for
hll'll transportnion needs if fatigueallem ability to driYt. Pro~
Itl!fal )'faJ! alter themothtrapy.)
_ _ _"--"
"=""',1,,to lOCiallfrmts IS netded.
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'1101'1,,37
Drug'(D<f\IeopLHIa
5 67
I'rovidt lor tmOliollill suppon for t~ patien~ family, and (.Irtgmr. (Can't!
rf"IUkl in profound . motionallt'lroOOlirom all inrolY!'d. EnWUri9f
di=ion of ,olUm ~ appropriatt It'I. rra II lor !O<ia Isupport or spirilwl
asliS!iIl(.,and ,1IIlnl t~ patient or family for dilufI! that may It'quilt'
m.ntal ~alth ~Ierral.)
Ttllh tiMo Pitient about t~ nw:! for flt'quent monilOring of "rdiil IUM.
Immtdiateiy repln any lhest-wall pain.angina, palpitatiom,~pnea,lung
longtltion, or dizzinell.
CYlliti~.)
dizzines~
(Continued)
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568
kICh the p.lDent 10 inspt(l mouth at IrlSt once oWy 1M m~tlin regWI
Mnt.ll wms.Miintain good onl tryqitnt and rinse mouth with plain
wate l 01 iOUion Ifttl eatill!l.Use anl~al and ilntifunrJal mouth
rinses and do not rinse mouth with Willtt' iftel usinQ, kfoid txHSMiy hot
()'cold foods.
kICh tilt p.lDent 10 ill'Oid high-lOUghilgt foods, spier foods,carool\lltd
Ind acidi.: bMrage,ilkohol, and uffHlt.HdiantIt.J is Ifftl!'. drug
therapy mry bf requirtd.lmtlWdiattl1ltpOfI ~ny excHSM dia nbti,
rspecially lit (ootlm IIIIKlII Of blood.
gimg chemolhtfilflJ
The p.ltien~ fimiiy. ()' UregMor UIouId bf able tostatt tilt ItISOll for the
dlUlj;lppropr~tt dost Ind sd!e!kJlinq;whil adverw tltKb (0 obstm 10,
ilnd whm to rtpoft; ilnd the ilnticipated length of mediution theril""
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1KIiInI:"".
(lIopltll7
Drug'fo<~
569
37.2
The causes of cancer may be chemical, physical, or biologic. Many environmental and lifestyle factors are asso ciated with a higher risk of cancer.
17J
37A
H .S
The growth fraction, the percentage of cancer ceUs undergoing mitosis at any given time, is a major factor determining success of chemotherapy. Antineoplastks are
more effective against cells that are rnpidly dividing.
"Ib achieve a totat cure, every malignant cell must be removW or kiUed through surgery, radiation, or drugs, or
by the patient's immune system.
37.6
17.7
37.a
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a day."
4. "I am taking my lS-month-oid granddaughter to the
pediatrician next w~ek for her baby shots.~
5. "I am going to go shopping at the mall next week."
2. serum electrolytes.
l. CDC.
4. bonescan.
A 2-yl'.lr-old patienlis receiving vlncrlstlne (Oncovln ) for
Thl' n urse nOies tha t the patien t has reached his -nadir."
This means that:
I. thepatient is rtaiving the highest dose possible of the
chemotherapy.
2. the patient is experiencing bone marrow $uppnssion
and his blood oountJ an at their lowest point
l . the patient haspraktd on his chemotherapy ltwl and
should be going home in a f"" d3)'S.
4 . the patient is uperiencingt"l:tremt depresdon and wiD
be having a psyt.hlatrk consult.
l. Stomatitis
4. _
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r::--'- ~"---.
EXPlOflE ~
P.eg13l~.,ow IICI:tJiII
www.mrllll.linilkitcam.
U NIT
l he Respiratory
System
(HAPTER 38
CHAPTER 39
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DRUGS AT A GLANCE
LEARNING OUTCOMES
Hf RKIPTORANTAGONISTS (A NTIHISTAMINES)
",,,,
,.,,,,
diphMhydrD~(B~,OfhfflJ
INTRANASAL CO RTICOSTEROIDS
,-,511
<;) flu/mOtIf IfJMcose V"IImyst olhmJ
""w
o.rynfazol~c:Akifl,o!hffJl,.W
ANTlTUSSIYES
,.w
Q <h~fholpht>n (l:W.I)'fI1,IIobinmm.
olhm) pillJt511
EXPKTORANTSANDMU{OLYTI!3 1'11'584
8. Use the nursing proc~ to call! for patients who are receiving
pharfTliloCotherapy for i\lliergic rhinitis and the common cold.
KEY TERMS
ilHeIJI'Il fIIJ1t 574
mlKllJl:i:5
felloW (ongetiln
.nlossi'll5 JIIlIJ'5&J
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JIIlIF J!5
ptIJt 1II1
'"",If,31
result in death. When functioning properly, this system provides the body with the oxygen critical for all cells to carryon
bases,a topic presented in chapter 31 co .This chapter examines drugs used to treat conditions associated with the upper
573
InI...",.
"""""
Vestibule
Hard palme
a.alaM!y
11I.L\;':i:t---
Laryngopharynx
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ALLERGIC RHINITIS
o r hay fovtr, is inflammatkln of the nasal mudue to exposure to altergens. Although not tife threat-
AI~rgi<rhinilil,
(<=
38.2 Pharmacotherapy
of Allergic Rhinitis
Symptoms of allergic rhinitis resemble thoSt" of the com -
mon cold:
h~arin8
eyes, snet'ling,
n~ 1
oongestion, posl-
symptoms, polenti31 complications of allergic rhinitis ind ude loss of taste or smell, sinusitis, chronic cough, hoarseness, and middle ear infections in chil dren.
As with other allergies. the cause of allt"rgic rhinitis is exposure to an antigen. An antigen, also cal led an allergen, may
be defined as anything thaI is recognized as foreign by the
body's immun e defenses. The specifk allergen responsible
for a patient's allergic rhinitis is often difficult 10 pinpoint;
however, the most common ngents are pollens from weeds,
grasses, and trees; mold spo res; dust mites: certain foods;
and animal dander. Chemical fumes, tobacco smoke, or air
pollutants such as OlOne are nonallergenic factors that may
worsen symptoms. In addition, there isa strong genetic pre
di,p06ition to allergK rhinit~.
Some patients eJ:perience symptoms of allergic rhinitis
only at specific t imes of the year, when pollen levels are at
h igh le"els in the environment. These per iods are typically
in the sp ring and fall when piants and trees are blooming,
thus the nam e ~QS(}n(l1 alJergk rh in itis. Obviously, t he
"bloom ing" season changes with the geographic location,
and with each spies of plant. The51:' patients may need
pharmacotherapy for only a few months during the year.
Other patients, however, are affiiaed with a1lrrgk rhinitis
throughout the year because they are cOfllinuoulilyexposed
to indoor allergens, such as dust mites, an imal dander, o r
mold. This variation is called ptfennia/ allergic rhinitis.
These patients may requi re cont inuous phannacolherapy.
It is o ften not clear whether a person is exprriencing seasonal or perennial allergic rhinitis. P:itients withst"asonal allergies may also be ~rtSirivt to some of the perennial
aUrrgens. It is also common for one all ergen to ~sensitizew
the patient to another. For example, during ragweed season,
a patient may become hyper-respo nsive to other allergens
such as mold spores or animal dander. The body's response
and the symptoms of a llergic rhinitis are the $lime, howewr,
regard less of the specifi c allergen( s). Allergy testing can help
to pinpoint the specific allergens producing the symptoms.
The fundamental pathophysiology responsible for allergic
rhinitis is inflammation of the mucous membranes in the
nose, throat,and airways. The nasal InUCO$3 is rich with mast
ceUs (a type of connective t issue ceU) and basophils (a type
of leukocyte), which rtoognile environmental agents as they
try to e nter the body. Pati~nlS with allrrgic rhinitis con tain
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""....
containing
histamine
AlIe'll' p I _ cell
reIe_ -.IIergy"
Bnmgoite
fo< ....rgy
-"-~''''~
Pelt"" binds to
allergy anlibociw,
CItU5lIOI hist ........
.......
~
-\
H,-Receptor Antagonists/Antihistamines
Antihistamines block the actions of histamine at the H, receptor. They are widely used as over-the-coWlter (OTC)
remedies for relief of allergy symptoms, motion sickness,
and insomnia. Theseagents are listed in Table 38.1.
TABLE 38.'
HI-Receptor Antagonists
"n"
FIR5T-GENERATION AGENTS
Adverse EifKt5
alflutillt (,l.sttlin)
~mutillt
~ramillt
OOU~l'Omirn;
(lavist)
qproheptadilll'
(Drinran
PO;6mg bid
diMnlrfdrilal! (Dramamile)
Q tip/lffih)'1hmillt (Bmodryl,OIhffi)
prometlwillt (PhfIII'~n)
triprolidilll' (Zymilt)
SECOND-GENERATION AGENTS
miizilt(qml)
dtsloratadin ~ (Oarilltxj
iexom!adilll' (ldltgra)
If\'ll(~tirizilll' (X)'lin
Ioratatillt (OariIin)
PO; 10 mglday
oIopatadilll' (Patanalf)
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575
S76
Un'"
TABLE 38.2
Brand Name
Antihistamine
DecongMlant
dIIorp/Iffiiamilr
p/IffiyIqtlriM
Adiftd(old andAl~
dIIorphtni'amilr
diphtrtlydl"DirM'
p/IffiyIqtlriM
p/IffiyIqtlriM
dIIorp/Iffiiamilr
brompheniramiM
~iM
dIIorp/Iffii'Jmilr
p/IffiyIqtlriM
diphtrtlydl"DirM'
dtmaSliM
p/IffiyIqtlriM
Triamiri( CoIdfAlItqf
dIIorp/Iffii'amilr
p/IffiyIqtlriM
TyIffioI AI~SirLHapieu
dIIorp/Iffii'amilr
diphtrtlydl"DirM'
p/IffiyIqtlriM
tJvi51 AI~tlblt;l
TyIffioI PM GtkapI
f.
p/IffiyIqtlriM
"
Analgesic
ADVERSE EFFECTS
ADMINISTRATION ALERTS
Th~re isan inC"N1e:i rilkof anaphy\.lcti[ lhock whrn Ihis drug is adminis
tmd parrmrwlly.
Whon .dministorirog IV, injro ~t ~ rolo of 25 mgfmin to rro~ tho .iskol
,hod.
INTERACTIONS
Drug-Drug: u.. with CNSdopr=ll\tl """ ;><akohot or opioidI wi. """" in<JNSf<i
Ioed.!lioo.0tIw orc mid ]llfllill"ationI may ioo&JIt antio:hoIiM"riI: ~ Plftm.IMO
Wh~n .dminr.l~rirog 1M, injKt drt"p into J largr mUlde 10 minim~ tislUl'
irritltion.
PR'gnallQ ~ry C
Duration:4- 7h
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side effects, whereas the second-generation agents---loratadine, desloratadine, and fexofenadine---produce the least.
Although most antihistamines are given orally, two are
availablt' by the intranasal routt'. Azelastint' (Aslt'lin) is approved for nonallt'rgic rhinitis and is as safe and efft'ctive as
the oral antihistamines. Although a first-gt'nt'ration agt'nt,
azelastine causes less drowsiness than others in its class because it is applit'd locally to the nasal mucosa, and limited
systt'mic absorption occurs. Olopatadine (Patanase) is a
second-generation antihistamine approved in 2008 for allergic rhinitis.
In addition to allergic rhinitis, antihistamines have been
used to treat a number of other disorders. These include tht'
following:
Flutlcasone
P~nalK)'mf9ory(
Intranasal (ortieosteroids
Corticosteroids, also known as glucocorticoids, may bt' applied directly to tht' nasal mucosa to prevt'nt symptoms of
allergic rhinitis. They havt' largely replaced antihistamines
as preft'rred drugs for tht' treatment of perennial allergic
rhinitis. These drugs are listed in Table 38.3.
ADMINISTRATION ALERTS
IOIlIlKl tht p,tM<m to ""wily follow tilt di~(\iolll for 1M providtd by
tlMo manufa{\uftl".
ADVERSE EFFECTS
AdYel"5t rlffi:u of fkni<a!OOI' i ~ "'~. Swallowing large amounu in(~alts tht
pot~mial 10, 1)"I\I1mic: (ortKolleroid ,dvmr tfftru. Halal irrimion IOd~
uris oc:rur in a !In.JlIrumoo of patitnts.
Contr aindi w ions: TIMo only (ontlainal(.Jtion to flutiu!OOI' iI prior h~ptr=l~
tivity to the drug. ~Ir ronic:olleroich (ao mask lignl of ioftion. patitnts
with knowo bmtrial, vira~ fungal. 0' pmlitic: inn(1ions (rlptCialiyof tilt rtspi,atorytrad) lhould oot It iYr intraoal.ll (ortKoltrroids.
INTERACTIONS
D"'!l-Drug: ""-niOOl "'" or on inWII>UI dKongomnti.{J..... thtrilkof
n.JI.Il ilrimion (I bl@tdng.lMwim ritOMifst.U:i ~awidfd.a5 m~ dru9
PHARMACOKINETICS
Onset:Unknown
~k: Unknowo
Halflifdh
Duration: 11- 24 h
lib Testl:UoUlc!m
Herba VFood: 1M with Cilk'tion wi!llliurice. wIid1l11irf poifOtioft iIIf ~ 01'
(0!Iic:0III'I00I.
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577
578
U"IU
n..lle\.plruorySystem
Anes5ment
BI5t1ift t tiStnmut prior toadmin istrMion:
UOOerstalld the re~so~ tilt dNg his betn preaibed ill otder to ~sstSS for
thmpMK ~cts.
Obuio ~ (o.~ ~Ith history including piMM histofy of symptoms
Ind a\soonion to ~1 5OOl.. took, or frwironmmloili HpOWfI'S; nisting
ca!d'Mrmcula(, ft'Spiratofy, lItpatic,ltnal. or nMOIogic d'~;9ial/Cl)ma;
PJOIt.ltK h)'ptftlOphy or diffi<ulty with urinition; pmtI1<t of r-r Of actM
inIKtiom; pregnancy or brea\t -lffiIing; ~kohoIl/Sf; or smoking. Obuin ~
dlUlj history, noting the t)'pe of aclvrlSe ItKlion or .nrrgy "prrienc~ to
Iny mf<licaliorts.
Ha~rw symptolll'l are of lIN on~I,i'S~ for any ItCrnt ciwongH in dirt
so.I pi, cosmttia,lotions, r rIYironment, or rHtnt urptt ooning. polrticularly
in infants and young childrrn.
Obuin bmline vitll signs. All ECG rnaJ 1M! Ofdfled for p"itnts with.
history of CinflK concfitions.
[v.~u "pPfOpMe ~mory findings (e.g.. (8(, hepatK~nd reJljj bbs).
F~1i9Jr
Expr""oc~ ~apMic: rffKts (t.g..dKrea~ nalill (Ongmion and draina9f,dr<It~~ ~watffing.nd Aching).
Br frtr from,or ~ minimal. aclmst ~ffKts.
Vtrbaliz~ an undMtanding of the drug's IIIl', adwBt tfftcts.and r!I:FIirtd preuutions.
Dtmonstntt proprr seIf__ inistration of tilt med'otion (t.g..dosr, timing. when to' notify ~l.
Implementation
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....".
579
InstllKt Iht patitm on the netd to rtrurn periodieally for lab woll
AsltIs for change"! in visual acuity, blurred vision, lassof ptriphtral fision,
sing rainbow halos around lighu,irutt f)'t pain,or iny ofthese
symptomsac:comj)anitd b~ naul!'a and vomiting arod rt'port immrdiatd-,-.
(lnc~,std imriocular prt'>5Urt' in paritms with narrow-anglt glaUComi
may occur with imihistamine.)
Thr patitm shoukl bI' able to staU the rt'ason for the dlllCj,ippropriate
d,w,~nd <rhNlulilll]. whit .r!....... ..ti"I'<1S In nb< ....... fotand wh." rn
rtportthem.
a~iI.)
(Continued)
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580
Unit,
TheR"'PIrotorySY'!em
IIOSIril bid-qid
Tromimlrmi1l imrQrioo,lMri~
Prototypt Drug
""'"
snmifH},oro:t)'fll'l.!
Hyproortidsm (only ij lamt amoonu
OOtIOOKR (Omnaris)
momtlillOlll' INaIOOO:)
triamdooiOlM' aatooidt (NuiI(O/t AQ)
Adverse Effect~
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a(CwDowrdl
Decongestants
Decongestants are drugs that relieve nasal congestion. They
are administered by either the oral or intranasal routes and
are often combined with antihistamines in the pharma.
cotherapy of allergies or the common cold. Doses for the
nasal decongestants are listed in Table 38.4.
'"",If,31
581
~ot(PJfU-{l)
InrroOORlI:uonIil'lJlrJOJOlim~orion.oo~
~my 4hll
IIiphazolint: (lmiw:)
[Amn ~ Hoo~
Hto-S)TItphriot 4- 6 HIHI",OIhtrs)
. ,"'"
.-
AdwI'5l! Effect,
1f:uihydroldiot (Tyziw:)
xyIomrtllOliot IOtrivin)
ANTICHOLINERGIC
ipritropiJm brom~[Atroml~
CorrbiI'mt)
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"""'"
monitor distribution of pseudoephedrine by kt'eping a log
of patient names and address, checking the photo identification of the buyer, and limiting the quantities of the
drug that are sold at one time. It should be noted that
these precautions are not being taken because pseudoephedrine itself is a dangerous drug, but to limit the
availability of the drug to illicit makers of methamphetamine. Manufacturers have reformulated their OTC cold
medicines to contain phenylephrine rather than pseudoephedrine. A drug prototype feature for phenylephrine
is included in chapter 1300.
B<'C3USe the sympathomimetic< relieve only n~sal con_
gestion, they are often combined with antihistamines to
control sneezing and tearing. It is interesting to note that
some OTC drugs having the same basic nante (NeoSynephrine,Afrin,andVicks) may contain different sympathomimetics. For example, Neo-Synephrine decongestants
with 12-hour duration contain the drug oxymetawline;
Neo-Synephrine preparations that last 4 to 6 hours contain
phenylephrine.
One anticholinergic, ipratropium (Atrovent), is used as a
decongestant. Given by the intranasal route, ipratropium
has no serious adverse effects. Its actions are limited to decreasing rhinorrhea; it does not stop the sneezing, postnasal
drip, or itchy throat or eyes characteristic of allergic rhinitis
or the common cold. A more conunon indication for ipratropium is in the pharmacotherapy of asthma, and a prototype feature for this drug may be found in chapter 3900.
ADVERSE EFFECTS
ADMINISTRATION ALERTS
~nt
anisocoria (blurTfd
PHARMACOKINETICS
IAtset:S - l0min
Peak:Unknown
Half~ife: Unknown
Duration:6- 10h
H OME
&
!Wiliowfd.
Contraindimions: Pat;'nts with Ihyroid disorder;, hypentnsion, diabete~ or
he.n disNst should 1M sympathomimttit5 only 00 the dirl'dion of their
heakh carl' pw;idtr.
INTERACTIONS
I)ug-l)ug: tIo diiYIly imporunt interaaions 0(01; bKaust ibsorption of
QI)'IMaldill' illinitfd.
LabTem: lktoown
IlerballFoo:l: IJSI' with caution with herbII ~merlllsum <II St. John~ won tIwt
ilavr propI'I1itI: of mono;ull.... OxWIf inhlJitor;.
same drugs classes used for allergic rhinitis, including antihistamines and decongestants. A few additional drugs, such
as those that suppress cough and loosen bronchial secretions, are used for symptomatic treatment.
Antitussives
Antitussives are drugs used to dampen the cough reflex.
They are of value in treating coughs due to allergies or the
common -cold.
COMMON COLD
The common cold is a viral infection of the upper respiratory tract that produces a characteristic array of annoying
symptoms. It is fortunate that the disorder is self-limiting,
because there is no cure or effective prevention for colds.
Therapies used to relieve symptoms include some of the
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38.6 Pharmacotherapy
with Antitussives
Cough is a natural reflex mechanism that serves to forcibly
remove excess secretions and foreign material from the respiratory system. In diseases such as emphysema and bron-
(""'1f.31
to suppress the cough reflex are very low; thus, there is minimal potential for dependence. Most opioid cough mhtures
are classified as Schedule III, IV, orV drugs, and are reserved
for more serious cough conditions. Though not conunon,
overdose from opioid cough remedies may cause significant
respirutory depression. Care must be taken when using these
medications in patients with asthma, because bronchooonstriction may occur. Op ioids may be combined with other
agents such as antihistamines, decongestants, and nonopioid antitussives in the therapy of severe cold or flu symptoms. Some of these combinations are listed in Table 38.6.
Adverse effectl
rodtilM'
On"
ANTTTUSSIVES: OPIOIDS
""'' '"
!iepmlioo
orr
Wtre IOmoolroce
ANTITUSSIVES: NONOPIOIDS
bmzonalat~ (T~lilon)
dtllltmttholphan [Dtbym,
'"""'"
PO; 200-400 mg f'/!f14 h (max: 2.4 glday)
En~ rflNSe PO;600-1,200 mg Mry 12 h (mB: 2,400 mglday)
MUCOLYTIC
ac~tykySlm~ [Ac~udol~
MlKomyst)
cuOOprja jQlOmnia
EXPEC10RANT
RobiIUI~n,otlltrs)
trl'mor;
RobiIUI~n,othtrs)
guaifmtsjn (MlKilM'l,
Hosrnous~dkm
TABLE 38.6 ! Selected Opioid Combination Drugs for Severe Cold Symptoms
Trade Name
Ambtn)"l Cou91 Syrup
Oplold
codrillt
bromodip/lffihydramillt
codrillt
ulciLm iodm
HycoillSS bptctOfanl
h,.._
h,.._
h,.._
h,.._
h,.._
h,.._
HovahislilM' 011
codrillt
CaIOOi~ S)TI4l
CodamilitSyrup
Codioo, 011 Syrup
Codimal DH
Hycodan
HycomiM Compoood
P~nwllhCodthf
Robilus~n
A-C
T*TUI~n S)TI4l
TUllionn
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h_
"".
h,.._
codri~
58 3
phtn)"lpropinolami~
guanffirlin
phtn)"ltphri~ p)'Iiami1~
homauopilM'
_...
phtn)"ltphrillt,cblorp/lNirami~,ac~taminop/iffi
guanffirlin
pstIIIIotp/Itdi~,cblorpllffiiralli~
guanffirlin
p/Iffi)"ltphri~, cblorp/lNirami~
cbiorp/lffii,amilM'
584
The most frequently used nonopioid antitussive is dextromethorphan, which is available in arc cold and fiu
medications. Dextromethorphan is chemically similar to
the opioids, and also acts on the eNS to raise the cough
threshold. Though it does not have the same level of abuse
potential as the opioids, in large amounts dextromethorphan symptoms of abuse include slurred speech, dizziness,
drowsiness, euphoria, and lack of motor coordination.
Benwnatate (Tessalon) is a nonopioid antitussive that acts
by a different mechanism. ChemicaUy related to the local
anesthetic tetracaine (Pontocaine), benzonatate suppresses
the cough refie)! by anesthetizing stretch receptors in the
lungs. If chewed, the drug can cause the side effect of numbing the mouth and pharynx. Adverse effects are uncommon,
but may include sedation, nausea, headache, and dizziness.
then be removed more easily by coughing. The most effective OTC expectorant is guaifenesin (Mucinex, Robitussin,
1l'J(1 ~JlfiJ5.l&ji
ADVERSE EFFECTS
ADMINISTRATION ALERTS
At thtr~ptUlic dose, aderst tiftds rut to dextlOlllflhorphan U~ rare. DiuiIM'II, drowsilM'ls, ilnd GI Upltl occur in !OIIle piltitm~ In iibull' lituations, the
drug can caUll' CNS toxicity with a Mde variHy ofs~mptoms, including IUlTI'd
IptfCh, ataua, hyptrexdtlbility, IIUPO~ rtIpiratoty dtprellion, lI'izures, {lima,
and toxic psydmis.
Contraindica\ions: Dmromtthorp!wn is cOlltr,iOOiUltd in t~ lreillmtm 01
chroniccoughdUl' tO tJl(~ bronchial~retions,sumas in althma, IIIIOking,
indernph)"ll'llla.Suppl!"lling t~cough reIIex is 001 ~ilible in thf2 patitntl.
INTERACTIONS
l)ug-l)ug: IlnMj inlfliCliJnl with dutrOlll@ihorphaniKkIde!nitation,
ir,'polfnsioo, and Ir,"pp)m:ia whi>n UIfd C(OOlfflltly with MAO i"lhibitori.lIst
with aImhot, opioids, or other 015 dfpreSMlts may r!!Ut in IfIIalion.
f'eak:Unknown
Half~ife: Unknown
Duration: J~h
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(""'lfr 31
others). Like dextromethorphan, guaifenesin produces few
adverse effects and is a common ingredient in many OTe
multisymptom cold and flu preparations. It is most effective
in treating dry, nonproductive cough, but may also be of
benefit for patients with productive cough. Nonprescription
cough and cold products (including those containing guaifenesin) should not be used in ,hildren under 4 years of age.
Acetykysteine (Mucomyst) is one of the few drugs available to directly loosen thick, viscous bronchial secretions.
Drugs of this type, which are caUed mu(olytics, break down
the chemical structure of mucus molecules. The mucus becomes thinner, and can be removed more easily by coughing. Acetylcysteine is delivered by the inhalation route and is
585
not available OTC. It is used in patients who have cystic fibrosis, chronic bronchitis, or other diseases that produce
large amounts of thick bronchial secretions. Mucomyst can
trigger brochospasm and has an offensive odor resembling
rotten eggs.A second mucolytic, dornase alfa (Pulmozyme),
is approved for maintenance therapy in the management of
thick bronchial secretions. Dornase alfa breaks down DNA
molecules in the mucus, causing it to become less viscous.
Acetykysteine (Acetadote) is also administered by the
oral or IV route to patients who have received an overdose
of acetaminophen. Its use in the pharmacotherapy of acetaminophen toxicity is presented in chapter 3JOO.
Assessment
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._,
....".
Cominut 10 moniflll vitil signs,tspiilly pulse r.le MId rhythm for P'litnlS
taking MtongrsuMS. incbfing rwwl dKOngetlnlS. (Srm p.thomi~til:
~tanu miY C.IM OO)'C.olnii and drsrhythmiil in patitnts with
h~IOI)' of c diINSofJ
""'.,.
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C"",lfr31
Drug<
587
The !)atitnt and fam iIy orurtg~r art' i ble to discuss appropriale dosing
and administralion ntfds. induding:
u,ugir supprtS.S<Jllfl:Cough syrups Ihould be IwallaMd withoot wuer
i nd allowflf to (OU the throat for soothing tffe(\~ foilaWl'd by
ilKll'iIStd fluid intake 30 10 60 minutes laltr.
&ptcraran/!::S)TUps should be tal!rn with a IuligliSs of liquid and
ilKrt'aIfd fluid intake Ihroughout tht clay 10 mist in thinning mucul for
Nit of tlpeuoration.
Nasal dPt.oni~Qnn: NiSal pdSsagI'S should re(leared t, blowing.
follaMd by the OiIal'pray.
Evaluate the tfrectil'l'lltsl ofdrug therapy by (onfinning that !)atitmgoaisand H pKle<t oU\(omtSh",'f ~ met 1="Planning").
5tf T6Ne: 3"-3, 38.4, 3H , ~rrd .J.!.6 f,.. aliM of dfl!lJI re which rIIoIllJIIsing aailJllupply.
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not clear, refer to the numbered section within the chapter for review.
38.1 The upper respiratory tract humidifies and cleans incom
in g air. The nasal mucosa is richly supplied with vascular
ti5sue and i5 the lim line of immunologic defense.
38.2 Allergic rhinitis is a disorder characterized by sneezing,
watery eyes,and nasal congestion. Pharmacotherapy is tar
geted at preVl'ming the disorder, or relieving its symptoms.
38.3 Antihistamines, or H, receptor anmgonists, can provide
relief from the symptoms of allergic rhinitis. Major side
effects include drowsiness and anticholinergic effects such
as dry mouth. Newer drugs in this class are nonsedating.
38.4 Intranasal corticosteroids have become drugs of choice in
treating allergic rhinitis due to their high efficacy and wide
margin of safety. For maximum effectiveness, they must
be administered 2 to 3 weeks prior to allergen exposure.
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588
re.;eptor
ant~gonisl.
2. Itching.
3. dryskin.
4. increased restlessness.
Which of the following is the hfl advice that the nurse
can give a patient with viral rhinitis who intends to pur_
chase an OTC comblnallon cold remedy!
1. Dosages in these remedies provide precise dosing for
each symptom tlJ.1t you areexperien<:ing.
2. Theseagents are best used in conjun<:tion with an
antiblotl<:.
3. II Is safer to use a lingle-agent preparntlon If you are
only experiencing one symptont
4. Since these agents are awilable over the counter, it is safe
to use any of them as long as needed.
2. A 65-year-old p~tient has bronchitis and has been coughing for several days. Of the two antitu~ive medications,
denromethorphan and codeine, which is the drug of
choice for this patient! Why!
3. A67 -year-old patient has allergic rhinitis and always carries
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to lake flutlcasone and a week late r ca lls the provider's office and talks to the nurse. He says, "This Flonase is not
helping me."What is the nurse's best response!
St:e Appendix D for answers and rtltionll/u for 1111 activilies.
EXPLORE
~.-----,
~eol.~er)OO1 IICce~
DRUGS AT A GLANCE
LEARNING OUTCOMES
Antlchollnwglcs
plllJt594
Methylxanthlnes jllJlJt595
ANTI-INFLAMMATORY AG ENTS
ptJIJt595
Cortkosterolds 1"l1'595
Q b/><:lomnha.otIf' I8I'COfIQ~ AQ OIar)
""'~
jlIJIJUi XJ
zafirlukast (Accolate) fI1IJ'6IJ1
KEYTERMS
ar,1 _ '~ I
il!thma
emp~ma p!JIJt6IJ 1
fllXY 591
bronmospivn
jIIJIJt 591
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leukotrienl5
_m
p!JIJt 599
n, buli,
p!JIJt 5~1
perfusion pa]'5'XJ
stat UI m hmatirus
p!JIJt 591
ventilatiln
p!JIJt 5'XJ
p!JIJt 59]
590
Unit,
TheR"'PIr~!o<ySym'm
capillaries. An extremely thin membrnne in the alveoli separates the airway from the pulmonary capillaries, allowing
gases to readily move between the internal environment of
the blood and the inspired air. As oxygen crosses this membrane, it is exchanged for carbon dioxide, a cellular waste
product that travels from the blood to the air. The lung is
richly supplied with blood. Blood flow through the lungs is
called prrfusion. The process of gas exchange is shown in
Figure 39.1.
Expired air
Trachea
Left lung
Left primary bronchus
""-"'
blood circulated
back to the heart
Diaphragm
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O~pltll9
Pulmonary O""rders
ASTHMA
Asthma is a chronic pulmonary disease with inflammatory
and bronchospasm components. Drugs may be given to decrease the frequency of asthmatic attacks or to terminate attacks in progress.
PHARMFACT5
Asthma
Asthma is resplnsiblto [0, mOK than I.S million emrlge'KY drpanrnrnt
flits and more than 500,000 hospitalizations r~(h ~u.
iIIore than S,5OO patiems die of asthma N(h ~a,.
Till' inddrna of asthma has bten dramatically ifl(reasing e>Kh yr. ~ml'
lilSO in all age,grnde-r,and f1hnic groups. Thehigh~t liIil'ofifl(ft'lIr has
Iftn among Afriun AlIII'riuns.
Till' highest inddenc:f of asthma is in patients )'JUnger than <Igr 18; from
7lI. to ]()% of(hildrrn haYe the disNsf.
lnadults,asthm<l islS% morl'(ommon in womenthan in IIII'n.ln
mildren,hOWfYl'f, thedisu~ alFrru twicr.Js many boys asgirls.
,.. Flgure39.2 [)@vlcesusedtodellverresplratorydrugs:(a) metered-dose Inhaler;(b) nebulizer with face mask;(c) dry powder
Inhaler
Source: fWxwn friKarkJ/l/PH College.
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591
592
Unit,
TheR"'PIf~!o<ySym'm
NORMAL BRONCHIOLE
I
Mucous m9l11brane
Smooth muscle
,.. FlgureJ9.3 Changes tn the bronchioles durln9 an asthma allack:(a) Normal bronchlole;(b} the Inflammatory component plugs
the alrway;(c) bronchoconstrlctlon narrows the airway
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O~plfl19
-.-
....
"-
Animal dander
Housthoid dUll
"Od
Chtmitalsand food
""'"
Sulfir~ prNIVa!W~
Potspi'uory infffiions
.~,
Emotional S!~s/il'lliU1
umill' io dry,(oId dimar~
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593
H OME
&
C OMMUNITY CO NSIDERATI O NS
------------ -- -
"
59 4
Unit,
TheR"'PImorySY'!em
Adverse Effects
BETA AGONISTS/SYMPA.THOMIMETICS
IItodiKhf,dilzinw;,
rmoo,
1If~11roof
mlQ~oo.drug ltMrooct
ridrtyroia.dysrhythmi.Jt hYDoQ!!fl1ia.
hypmly(m1ia. paradoxical bronm!XOl!lIrigion
12 h (ma1:14 mc:gIday)
pirbuterol (Muair)
Q !aimtlmll(SmI'mI)
DP~l~soI
tm..nalinr (~thinr)
A.NTlCHOLINERGICS
Q ipratropiJm (Al:flWm~(ornbi~tl
(mil: 12 inhalations/day)
METHYLXANTHINES
aminophyllilt (Truphylli1~)
po; 380 mgIda, in diridtd dosrs M!Y 6-8 h (ma1: 918 mglut)
Imlirilli ~rtOrrXiO
Tidrmroia. dysrhythmi.J\ hyDO!tllSion idnm,
cirwialory filure r@ralorurml
Anticholinergics
Although beta agonists are drugs of choice for treating acute
asthma, anticholinergics are alternatiw bronchodilators.
Only two anticholinergics are commonly used for pulmonary disease, and these agents are listed in Table J9.1.
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O~plfl19
595
Salmeterol (Serevenr)
ADVERSE EFFECTS
Seriou:! Idvrnl' elfe.:u from wlmetMlI ~re uncommon. Some p,tifml uptrierl(f he.Hbc:hes,thro,t irrimion, Ul'lllO~ nrlVOUSlM'U,l nd rt5tir!5l1!'15. BrulM
01 ii, pottntial to causr !am)'(ardia, patifnts with hun disul!' should bf monitolfll regularly. S,ll1IEteroi hiS a bbc:k box Wilming that LABk mly ilDf<lll'
the rislof asthma-~lated dmhs.
Contraindi cations: Salmetl'l'Ol!III' is cOIltrairodiutrd in patifnts with hypersrmitml)' to tilt drug and in patitnU Hptriencing uutr bronchosp"!III la
slionfl-Icting drug should be UII'd).Caution should be UII'd whtn umilg patiMu with dysrhythmia!, hypertension, hu n failu~ or Il'izUItS.
INTERACTIONS
Drug-Orug: (rorurrent U\I' with ~Ii bIoclal wil
ofsalmtlfll.
La b Ti5IS: ~mtlmI rna, {aU\I' hypobIi'mia.
PHARMACOKINETICS
Onsrt: lO-20min
P!ak: 2h
Halflil!: 3-4 h
Duration: Up to 12 h
The complete nursing process applied to patients receiving anticholinergics is presented in Nursing Process Focus:
Patients Re.::eivingAnticholinergic Therapy, on page 145 in
chapter 1300.
For additional nursing considerations, please refer to
Nursing Process FOUlS: Patients Receiving Bronchodilator
Therapy, on page 59:.
Methylxanthines
The ntethylxanthines were considered drugs of choice for
treating asthnta 30 rears ago. Now they are primarily re,erved for the long-term management of per,j,tent a,thma
that is unresponsive to beta agonists or inhaled corticosteroids. These agents are shown in Table 39.2.
with Methylxanthines
The mrthylxanthines, theophyUine (Theo-Dur, others) and
aminophylline (Truphylline), are bronchodilators chemically
related to caffeine. The methylxanthines are infrequently prescribed because they have a narrow safety margin, especially
with prolonged use.Adverseefftcts such as nausea, vomiting,
and CNS stimulation occur frequently, and dysrhythmias
may be observed at high doses. Like caffeine, methylxanthines can cause nervousness and iru;omnia. These drugs also
have significant interactioru; with nwnerous other drugs.
Methylxanthines are administered by the PO or IV
routes, rather than by inhalation. Having been largely re-
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Treatment of IMrdosr: OY!'rdoII' ltSuhl in an Haggtratro sympathetic ICUvatio n,u.lling dylrhythmial, hypokalfmia,'rod hyptrgl)ocrmia.ln seY!'rt mrs,administmion of , urdioll'le.:tive bftI-adrf lll'rgic antagonist may be lI!'(esary.
IItI'tf rc M}NurJlIIgKJI fr1r Q NurlIrrtj I'rrlm.! fooJs Jpl(1k RHIIIs drug.
Corticosteroids
Inhaled corticosteroids (lCS) are used for the long-term
prevention of asthmatic attacks. Oral corticosteroids may be
used for the short-term management of acute severe
asthma. These drugs are listed in Table 39.3.
with Corticosteroids
Corticosteroids, also known as gJucocorticoids, are the most
potent natural anti-inflammatory substances known. Because asthma has a major inflammatory component, it
should not be surprising that drugs in this class playa major role in the management of this disorder. Corticor.teroids
dampen the activation of inflammatory cells and increase
the production of anti-inflanunatory mediators. Mucus
production and edema is diminished, thus reducing airway
obstruction. Although cortioosteroids are not bronchodilators, they sensitize the bronchial smooth muscle to be more
responsive to beta-agonist stimulation. In addition, they red uce the bronchial hyper-responsiveness to allergens that is
responsible for trigguing some asthma attacks. In the pharmacotherapy of asthma, corticosteroids may be giwn systemicaUy or by inhalation.
"
ADMINISTRATION ALERTS
Tht proper In~ of the metered-doSl' inhaltr (MOO is imporuntto the effutiYl' drlm-IY oldrug. OWm!and instnKt tht patitnt in proper uS!'.
Wait2- 3 minutes bel'oYl'rn OOsagll.
ADVERSE EFFECTS
Bffi!M Yl'ry little is ablOrbed from the lungs. ipratropium prodKes ftw 1)'1tf mK adYI'ne ~ffKU.lnit,tion of thr upper re!piratary trm may re\Uk in
WJgh, drying of the llilsal m!Kosa, or hoanenl'll.1t prodlKfS a bitter IaItt,
whidl may be relieed by riming the mouth afler UII'.
Contraindications: Iprauopium is (ontraindicated in patitnts with hyptnensitwiry 10 soya lecithin or relatrd food products sum as soybfan and peanut. Soya
IKithin is usrd as <I propellant in the inhaltr.
INTERACTIONS
Drug-Drug: LMwlth othfrdllJ1l in rmdallw as atropill! marlNd 1O~1iI'f
antKhoIil\el~~fffPm.
Halllilr: 1.S-2 h
Duration:34ih
MverS(' Effects
INHALED CORTICOSTEROIOS"
IHIdtlOOicie (Pulmirortl
dOOonicie (Atw,sro)
f1urisolicle (AeroBidl
f1utiulOlll' (ROYI'Ilt) (II'~ palJl' >771or~
hyW'im litiYitY!f1jooS
PrototyprDrug boxOO )
momrlillOlll'(Almanl'l)
triamcinol~
(Mni(ort)
avmoIyn (Intal)
nedooomiisodilm (lilalle)
montrlubst (Singwir)
afirlwl! (A((oIitr)
lilruton (1y11o)
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IlI>pltll9
597
Assessment
m~dic:.ilion~
Implementation
Inte rventions and (Rationales)
Ensu,ing the,.peutic dfects:
Continue as~smtnts as dtsc;ribtd t.J rlitrlor tlltra ptUlic: tffects.(In(lNSI'd
toN of bll'athing; lessened adY!'ntitious breath sounds; impJOVtd signs of
tislUl' oxygenation; and normal .J ppeUte, tilling.and sleep patlffiI sshould
o((ur.Th~ hukh Wl' providtr IMuId be notifltd ~ symptoms wornn,
f'Sptwlly ilrrspirator, invo/vemt nt in(lNsrs or fel'fl is plrsenl)
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598
UnU
The~...pf~tofySys!"",
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Thf patifnt should be ablt to IUtt thf f1'ilOn for thf drug. appropriat~
dolt i nd IIhfduling. and what ad'R~ tff11 to oIurvt for and when to
report them.
IlI>pltll9
599
therapy by mnfirming that patirnt go;Ilsand oprdfd oUKomrs hal'(' bem met Isre PianninifJ.
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leukotriene Modifiers
The leukotriene modifiers are relatively new drugs used to
reduce inflammation and ease bronchoconstriction.
Leukotriene modifiers are used as alternative drugs in the
management of asthma symptoms.These drugs are listed in
Table 39.3.
600
Unit,
TheR"'PI,~!o<ySym'm
ADVERSE EFFECTS
B1o~haIGnt
Peak:30-70min
INTERACTIONS
I)ug-l)ug: lktoown
Half~ife:ISh
Duration: Unknown
acute asthma attacks. The currt'nt role of leukotriene mod ifiers in the management of asthma is for persistent asthma
that cannot be controlled with inhaled corticosteroids or
short-acting beta agonists.
Few serious adverse effects are associated with the
leukotriene modifiers. Headache, cough, nasal congestion,
or GI upst'l may occur. Patients older than age 65 have been
fOlUld to experience an increased frequency of infections
when taking leukotrient' modifiers. These drugs may be
contraindicated in patients with significant hepatic dysfimction or in chronic alcoholics, because they are extensively metabolized by the liver.
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CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
Chronic obstructive pulmona ry diseasr (COPD), is a progressive pulmonary disorder characterized by chronic and recurrent
obstruction of airflow. The two most common examples of
conditions causing chronic pulmonary obstruction are
chronic bronchitis and emphysema.
IlIopltll9
Oruq< /0,
60 1
Zafirlukast (Accolate)
ADVERSE EFFECTS
Zafirlukasr prod.:es few serious idve"" tff__ H ~i"""" is r.... """t<ommon
complaint, and naus~, ,nd dianhe. 'R' R'plnt<i by some ~titnts.
Contraindi cdions: Th. on~ contraindication is hy~""n~tivit)o 10 tht drug.
Ilfc.UIe a frw raR' castS of hepoJtic f.iklr. ha~ bffir R'plnt<i in ~titrru taking zafirlubst, those with pl!"-~listing hepoJti( impairm~m should ~ tR'att<i
with raution.
.rut.
ADMINISTRATION ALERTS
iM. ,sthlllil alli(D.
PHARMACOKINETICS
Onset:l wIr
Iflk: 3h
Halflife: IOh
Duration: Unknown
HOME
- --
&
-
COMMUNITY CONSIDERATIONS
- --- - ---- - - - - - - - -
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INTERACTIONS
Dru;rDrug: I.M with warfaoin may OOrnf prOlhromun tiM. Erythromyc .. may
decruSl'Sl'lUm lMokof i'ifi~ubst.
li bTests: bMukist may OOf<llol' IMJIl AU YiIIUfI.
HerbaVFood: Food till! rmu tMbioiII'ailabititr,thus,tMo-ug!hcQd hi' liter. on
Mlempt, stOll"liCh.
Treat mt nt of OW'rdose: Thert is no spKiIic trl'atmtm for cwrdose.
III!ftf Ie M)Nu/f IngIJf for Q Nrmlnl} I'rIKnJ fools ljIKlk ro rlrls ~
602
the visoosity of the bronchial mucus and to aid in its removal. Long-term oxygen therapy assists breathing and has
been shown to decrease mortality in patients with advan ced
capo. Antibiotics may be prescribed for patients who experience multiple bouts of pulmonary infections.
Patients with COPD should not receive drugs that have
beta-adrenergic antagonist activity or otherwise cause
bronchoconstriction. Respiratory depressants such as opi -
'';~~
Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the nWllbered section within the chapter for review.
39.1
39.7
39.2
39.8
393
Inhalation isa common route of administration for pul monary drugs because it delivers drugs directly to the
sites of action. Nebulizers, MDIs., and DPIs are devices
used for aerosol therapies.
A.'lthma i. a chronic disea.., that ha, both inflammatory
and bronchospasm components. Drugs are used to prevent asthmatic attacks and to terminate an attack in
progress.
39.9
39 ..4
39.5
39.6
The anticholinergic ipratropium is a bronchodilator occasionally used as an alternative to the beta agonists in
asthma therapy.
39.10 Mast cell stabilizers are safe drugs for the prophylaxis of
aMhma. Thq are I...... dfectiw than the inhal~d corticosteroids and are ineffective at relieving acute bron chospasm.
39.11 Chronic obstructive pulmonary disease (COPD) is a
progrer.sive disorder treated with multiple pulmonary
drugs. Bronchodilators, expectorants, mucolytics, an tibiotics,and oxygen may offer symptomatic relit'f.
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o..plfll9
II
603
Nursi ng assessment for a patient on long-term oral corticosteroids would include: (Select all that apply.)
1. assessing liver function tests.
2. assessing cardiac dysrhythmias.
3. assessing for signs of peptic ulcers.
4. monitoring blood glucost' for hyperglycemia
S. assessing for changes in level of oonsciousness.
Which of the following agents is .!!l2ll immediately helpful in trelting a severe acute asthma attack?
1. Bedomethasone (Qvar)
2. Zileuton {Zyflo}
3. Albuterol (Proventil, Ventolin )
4. Salmeterol (Serevent)
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EXPlORE
aq"il!li~h{g!fi:r-----'
Myflrsingllit I! yoor
on~ S!!l~
materialS
an~
a ctiV~s.
WYM.mynll"*'gIIltcom.
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U NIT
The
Gastrointestinal
System
CHAPTER 40
CHAPTER 41
CHAPTER 41
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DRUGS AT A GLANCE
LEARNING OUTCOMES
1'J'II'.10
ANTAODS
pI1Jt61;
ANTIBIOTICSFORH.PYWRI
JIl'll'ri15
KEY TERMS
Hrrutptorantagonist fllKlt6ll
ilntacid fl1I}'615
antiflatu lrnt (II1I'615
chirf(ells poqe6lJ8
rsophag~al reflUJ
HelicobQCttfpy/ori
ftl'1l' 6lI!
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ty.TJe6(1)
fX1I}t(D;
"
Hopa1ic II
,i
"
"
colon
colon
SaddIeRIver,NJ.
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Unlt7
PHARMFACTS
by the Stomach
Food passes from the esophagus to the stomach by traveling
through the lower esophageal (cardiac) sphincter. This ring
of smooth muscle usually prevents the stomach contents
from moving backward, a condition known as I5Ophag~aI~
fl ux. A second ring of smooth muscle, the pyloric sphincter,
is located at the entrance to the small intestine. This sphinc_
ler regulales the flow of substances leaving the slomach.
The stomach thoroughly mixes ingest ed food and secretes
substances that promote the processes of chemical digestion. Gastric glands extending deep into the mucosa of the
stomach conlain several cell types critical to digestion and
importanl to the pharmacotherapy of digestive disorders.
Ch irf (flls secrete pepsinogen, an inactive form of the enzyme
pepsin that chemically breaks down proteins. Parif tal (fils secrete 1 to 3 L of hydrochloric acid each day. This strong acid
helps break down food, activates pepsinogen, and kills microbes that may haw been ingested. Parietal cells also secrete intrinsic factor, which is essential for the absorption of
vitamin Bll (chapter 42(0) . Parietal cells are targets for
the classes of antiulcer drugs thai limit acid secretion.
The combined secretion of the chief and parietal cells,
gastric juice, is the most acidic fluid in the body, having a pH
of 1.5 to 3.5.A numbt>r of natural defenus protect thestomacb mucosa against this extremely acidic fluid . Certain cells
lining the surface of the stomach secrete a thick mucous
layer and bicarbonate ion to neutralize the acid. These form
such an effective protective layer that the pH al the mucos.al
surface is nearly neutral. Once they reach the duodenum,
the stomach contents are further neutralized by bicarbonate
from pancreatic and biliary secretions. These tl.1tural defenses are shown in .. Figure 40.2.
1
_ Gastric juice 2
.-----;;:~-=u-"O~'h
'"~"
pH -
Bicarbonate barrier
neulralizes acid .
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40.4 Pathogenesis of
Gastroesophageal Reflux Disease
Blood group 0
Smoking tobacco
Beverages and food containing caffeine
Drugs, particularly corticosteroids and nonsteroidal
anti-inflammatory drugs (NSAIDs), including aspirin
Excessive psychologic stress
Infection with Helicobacter pylori
The primary cau~e of PUD is infection by the gramnegative bacteriwn Htlirobttfpy/ori. Approximately 50% of
the population has H. pylori present in their stomach and
proximal smaU intesline. In lIoninfected patients, the most
common cause of PUD is drug therapy with NSAIDs. Secondaryfactors that contriblltt:to ulcer formation and subse
qut'nt inflammation include secretion of e."(cess gastric acid
and hyposecretion of adequate mucous protection.
The characteristic symptom of duodenal ulcer is a
gnawing or burning, upper abdominal pain that occurs 1
to 3 hours after a meal. The pain is worse when the stomach is empty and often disappears on ingestion of food.
Night-time pain, nausea, and vomiting are uncommon. If
the erosion progJ"eSles deeper into the mucosa, bleeding
occurs and may be evident as either bright red blood in
vomit or blac k, tarry stools. Many duodenal ulcers heal
spontaneously, although they frequently recur after
months of remission. Long-te rm medical follow-up is
usually not necessary.
Gastric ulcers are less common than the duodenal type
and haw different symptoms. Although relieved by food,
pain may continue even after a meal. Loss of appetite,
known as anorexia, as well as weight loss and vomiting are
more common. Rt>missions may be infrequent or absent.
Medical follow-up of gastric ulcers should continue for
several yea rs, because a small percentage of the erosions
become cancerous. The most severe ulcers may penetrate
the wall of the stomach and cause death. \'lhereas duodenal ulcers occur most frequently in males in the 30- to 50year age group, gastric ulcers are more common in women
uv"r ~I!" 60.
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6 10
PHARMACOTHERAPY ILLUSTRATED
40. 1 Mechanisms of Action of Antiulcer Drugs
Pmtoopunp
,mibil""
Proton pu m p in hibitors
~ind
to
the~ H~.
pn!I_
acid .ecrelion.
cellwilh
H,,-receptor
prolonpump
0"
......0 .. ... _ _ J
Antibiotic
.~
'- + -
___
~.~
HCL-
water + salt
00
0
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/\
6 11
",,"
Adverlie Effects
~(Ntxi!lll)
(f't!'Ii(id)
linlOpr.lld~
0, omtpI'amit IPri.-:)
(Protoril)
.,btpnlOlr (AdplltxJ
pant~
IIQ/k! iOlkatr ammon mr;r tlftn~ uodelliniog iolkate strilM adYmt r flta~
Pump Inhibitors
Proton pump inhibitors roouce acid secretion in the stomach by
binding irreversibly to the enzyme H+, K+-ATPasf. In the parietal cells of the stomach, this enzyme acts as a pump to release acid (a lso called H ~ ,or protorts) onto the surface of the
GI mUCO<3. Th .. proton pump inhibitor. reduc .. acid .<'Cre_
tion to agreaterextent than the H,-receptorantagonists and
have a longer duration of action. PPls heal more than 90%
of duodenal ulcers within 4 weeks and about 90% of gastric
ulcers in 6 to 8 weeks.
Several days of proton pwnp inhibitor therapy may be
needed before patients gain relief from ulcer pain. Beneficial effects continue for 3 to 5 days after the drugs have been
stopped. These drugs He used only for the short-term con
~ Prototype Drug
trol of peptic ulcers and GERD; Th.. typical length of therapy is 4 weeks. Omeprawle and lansoprawle He usoo concurrtntly with antibiotics to eradicate H. pylori. The newer
agents esomeprawle ( Nexium) and pantoprawle ( Protonix) offer the conveni.. nce of once-a-day dosing.
All proton pwnp inhibitors have similar efficacy and ad
verse effects. Serious adverse effects from drugs in Ibis class
~,.,.
H,-RECEPTOR ANTAGONISTS
The discovery of the Hrreceptor antagonists in tht 1970s
marked a major breakthrough in the treatment of PUD.
They have since become available OTC and are widely used
I Omeprazole (P"losec)
ADVERSE EFFECTS
Ad!'m tffM aft' gtntrally mioor and in{kidt htadac:ht, l\alMa, dicrrht.,
ra~h, lid ilbdomina Ipain.lhr main con{tm with proton pump inhibitors is that
Iong-tmn UIf has brrn moc:iatM with .n in{JNsed risk of gastric Cal(tI in
laborallry animals. ~sr of this possibility, therapy is gentraUy limitrd to 2
monthl.
Contr.indiutions; Tht on1)' rontraindic:ation is hyptl"l>l'nlitMty to thr drug.
OTC lilt is oot approvtd for patienu uncltr 18 )'I'ars of agf.
INTERACTIONS
OIUl}-~rug;Crorulmltllll' willi diaztpam, ~oi1,iIId(HS~nu mil"1
inaNw: the liWhood of blfeding. Akohol (;lO iHJ9'aviltl' the !iIOIIIidlIlUOW atd
dKJNs.! the fifutivmm of lJMP"iIldf.
_w.
HI'IiIiI Hood; Gioiato iIId St.1dVl~ won mil")' dKJNII' the pIaIrna ~uation of
~
.......
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Unlt7
TABLE40.2
H2-Receptor Antagonists
Dru,
Adwrse Effects
dm~diM' (~met)
PO;300 1119 ~\'I'ry 6 h 01800 mg .It btdI~ OI400mg bid with food
(Ptpdd, Mylointa AP I
PO;l~lOOmgoltbtdti~
(Axid)
rinitidilll' (lanta()
~k!m'~rision
40.7 Pharmacotherapy
with H2 -Receptor Antagonists
Histamine has two types of receplOrs: H I and H,.Activation
of HI receptors produces the classic symploms of inflammation and allergy, whereas the H, receptors are responsible for
increasing acid secretion in the stomach. The H,.~(eptor antag
onisl! are effective at suppressing the volume and acidity of
parietal cell secretions. These drugs are used to treat the
symptoms of both PUD and GERD.
All H,.receptor antagonists have similar safety profiles:
Adverse effects are minor and rarely cause discontinuation
fOr Prototype Drug
ANTACIDS
Antacids are alkaline substances that have been used to neutralize stomach acid for hundreds of years. These agents,
listed in Table 40.3, are readily available as OTC drugs.
I Ranrtrdrne (Zanrac)
ADVERSE EFFEaS
rmpton in t~Slolni(h todfill'u!'ac:id prodlKlion.1t hal ol higher palm')' lhan d~tidin~ whim allows it 10 lit administt rrd
onc:t dai~, lI!Wl~ al bedtin"l!'. Adtqwtt htaling of tht ukff I.kes approxim'~ 4to 8Wffks,ahhough tho!~ at high risk for PUD may (ontinue on drug
m.imo ... nc:~ for prolongod po>riock 10 p....... nt IUrrrn.li.><trK u~n rrqJilt:
longer thmpy for healing to oc(ur.1V and 1M forms 'I! aY.ilablt for t~ n atmtmof ,nM, st~l-indtnd blt~ding ukm .Trit is i (ombination drug with
ranitidi~ ,nd bismum dtral!'.Ranitidi~ is availablt in i dissoiYing tablet form
(EFFERd=) fortlNtingGERD in (hildrenand infanrsolder mol n1 month of agt.
tffects art unc:ommon and mild. Rnitidint doe 001 (rol!! tht
blood-brain b.rrier 10 iny appJ!(iabl~ extt nt. so it OO!'! nOI {aus~ the (onfusion
and CNS d~p~sion obserwd with (imetidint.Ahhough rail', 1!'\'I'fl' rrdlKtions
in t~ number of red , nd whitt blood (l'lk ,nd plal~ltrs all' possible;thUI, peri
odic blood count< lniybe pcrformrd High do~ ""'y rnuk in impotolKo or 10..
oflibido in mt n.
Contraindirnions: Contraindicationl inc:kKit hypersmsitivity to H,.rt plor
oIm"90nist~ aMt porphyrit, ind or( administration in childl!n Ie! than 12
yursofq.
ADMINISTRATION ALERT
INTERACTIONS
1Wg- 1Wg: blitidM has Itw drug-d"ug il!l'I"actioos than dmttidirll'.
Raritidillf may redtn thf .t.sorptiOl'l of {efpG!m~, kMlKOIIiroIf,and
itrar:onarolt.AnIiKids Ihoo.Ml no! be gil'l'Owitllil 1hoor ofH,-rtcfPlOl oIntagonisrs
beao.MthfeflKriI'I'IIfII may bf di'<JNIi u to rflkKfdabsorplion. ~kilMl
dPaui.fI thf ffI~ of raoi!icine.
PHARMACOKINETICS
I),set Unknown
Pf,ik:l- l h
Half~ifto: 2-1h
DUrition: 8- 12h
AdR~
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CNplfl40
613
Assessment
~Iine
AruIl'Pain
Ak .. ,t<1 Nurrition,lffi Than Body RfqJill'l1II'nn
Derl(ient KnowIl'dge (drug thl>rapy)
Risk for 1~Iflivt Health Maimf nalKf (lodjyidwl or Family;dietary ,od
liftstylechangtl)
--+
TNch the IHItirnr that full drug tlferu rna)' rake lI"/eIal days ro wtfn or
longer. Con>isttnr drug therapy wi II prafldt thr besr results. If 9<1stric
di~(omfort or pain (OnrinuforWOBtn afrflll'Vl'ral weeks of rhtraP1, the
health (a,e prafldtr >hoold be norifled.
Teach the IHItirnr rhat smlt abdominal pain orany blood in t rntsis or
stools should be r"POrted immedi.Jtt'ly to the heakh care prwider.
(Continued)
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Unlt7 lheGa'ilrolnt..,tI""ISymrn
Conlirue to monitor pfriodic hepatic: and rrul function trill ,nd (Be.
platrlm. ,nd rledrolyir ~Is. (Aboormallrm- fUnction I..,U may indicatr
drugindlKrd adYe.n hepatic rffrds.~~a\ed ROC. WOC.or platelets h,Ye
bffiJ noted with iong1mJl H,.recr ptor blocker iOOapy and dr<lNsrs
should bt I!poned 10 thr health ('R' providtr. m-s~Ye UII' of anudds may
affect ritrolyir 1eW'1s.)
EnsoR' patinlt safrty. rspK~lt; in oIdrr aduhs.ObIl'M fordiuinrss and
monitor ambuLllion unlil the rfi"Is of thr drug arr known.(Orowsinrss or
dizziness from H,reptor bIoc:urs may Q((ur. which inuralel thr risk of
falls.cMtinued dizzines!ordrowsinm may I"I'qJiR' a changr in drug
thrrap)'.j
Instruct t.... patirnt on the need to R'lum ptriod iully for lab work.
"""..
Pat ~nt
The patirnt, famit;. or taR'9iYer should lit able tostalr Ihr ~ason for thr
drug; .ppropri.N doI nd hodJling;what oct ........ffKtlIO obll'lft for
and when 10 R'pon; and thr antic:ipaied length of medicilion thrrapy.
Pat ~nt
E-Ialuatr the effectiveness of drug thrrap)' by (onfirming that patirnt goals and nptmd ou\(OIIII'S ha~ bet-'n mrl (1H P\anning1.
SH rli>lrl4IJ. ~ 4IJ.l.ooo ljf(K~ i1rridf'.llJllrl whidirirtst rNnirlgtimsopply.
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H OME
&
C OMMUNITY C ONSIDERATI O NS
TABLE 40 3 Antacids
Adult
0""
Rout~ and
1'O;600lIIIjtid- qid
CiJn5tipofiOfl, fI<ItI~wmlJ(h(fl!mp!
CiJn5tipofiOfl, IIorultllCt
migildrat~ (Riopan)
Dos~
Adverse Effects
&Ulim~iIlo Irooooho'gl:yl~miol
b)l!fWltfIllia DI:iIIUdi
mollJll'~lJIllrJdroxide (Milkof~)
(~~
(J(Jm{irll}
~nrlml~
mllrolrniil (wliffi
giYl'n Dartnterally)
hmmli!!!mli.!
I!QIk! indut~ ammon idvmr ~m;~in!kate sMousadwmr ~fIta~
40.8 Pharmacotherapy
with Antacids
Prior to the development of H,-receptor antago nists and
proton pump inhibitors, antacids were the mainstays of pepti' ulcer and GERD pharmaootherapy. Ind eed, nrony patients still use these inexpensive and readily available OTC
drugs. Although antadds may provide temporary relief
from heartburn or indigestion, they are no longer recommended as the primary drug class for PUD. This is because
antadds do not promote healing of the ulcer, nor do they
help to eradica te H. pylori.
Antacids are alkaline, inorganic oompounds of aluminum, magnesium, sodium, or calcium. Combinations of
aluminum hydroxide and magnesiwn hydroxide, the most
common type, are capable of rapidly neutralizing stomach
acid. Chewable tablets and liquid fonnulations areavailable.
A few products combine antacids and H,-receptor blockers
into a single tablet; for example, Pepcid Complete contains
calcium carbonate, magnesiwn hydroxide, and famotidine.
Simethicone is sometimes added to antacid preparations,
because it reduces gas bubbles that cause bloating and discomfort. For example, Mylanl3 contains simethicone, aluminum hydroxide, and magnesium hydroxide. Simethicone
is classified as an ntiflatu lrnl, because it reduces gas. It also is
available by itself in OTC products such as Gas-X and Mylanta Gas.
Self-medication with antacids issafe, when taken in doses
directed on the labels. Although antacids act within 10 to 15
minutes, their duration of action is only 2 hours; thus, they
must be taken often during the day. Antacids containing
sodium, calciwn, or magnesium can result in absorption of
these minerals to the general cin:ulation. Absorption of
antacids is clinically unimportant unless the patient is on a
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ADVERSE EFFECTS
ADMINISTRATION ALERTS
INTERACTIONS
[)ug- [)ug:AUnimrn (m1POUOOl !ht:Ud oot bf 00n with othfr rntduIiom, II
m., may n erlM with their olbsoIptioo.lkt with 1Odi:.m poIystyffM sulfonate may
(lIU"I,mmitl~.
Lab T.",: V.km f ....... op<lrin . nd oon ... , pit moy ilawst. \.or .... phosphO!.
lor u;e~.
R<ftr III MrImlrl9R till ~ MnJnq l'r!KeIS fIxrIs sp/It IIIIM /J"ug.
PHARMACOKINETICS
1Al1I:'t: 2Q--40 min
Pt-1k:30min
Half~i~:UnkMwn
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n.
Choplfl40 OnJg;Io,PeptkUIce<DI,,,,...
Misoprostol (Cytotec) inhibits gastric acid secretion and
stimulates the production of protective mucus. Its primary use
is for the prevention of p"ptic ulcers in p.1tients taking high.
doses of NSAIDs or oorticosteroids. Diarrhea and abdominal
cramping are relatively oommon adwrse effects. Classified as
a pregnancy category X drug, misoprostol is contraindicated
during prt>gnaJIcy. In fact, misoprostol is somE1imes used to
tenninate pregnancies, as discussed in chapter 4500.
Metoclopramide (Rt>gIan) is occasionally used for the
shortterm therapy of symptomatic, PUD in patients who
617
{~~ \ C-h-ap-te-rR-EV-IE-W------------------
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the oorresponding numbered section
within the chapter. If any of these points are not clear, refer to the nwnbered section within the chapter for review.
40.1
40.6
40.2
40.7
4005
40.3
40.4
40.10 Sewral misce1laneousdrugs, including sucralfate, misoprostol, and pirenzepine are also beneficial in treating
PUD.
40.5
40.9
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EI
II
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EXPLORE
~~-----,
M~l"$in[ll(~ 1s)'OOI one !IMp ItIO" Mline ~haplef r..,..lew matenllIs MI1
reSOLKO!&' Plepare for ~uccess with addiuMat Ncr..ue-!;tyt~ practice
ql>llStioro>. Intaractl"" as&lg1mants and aClI ..rllos. web tkll<&. amatlcl"ll
a<ld'lideo$ .8<ldmorel
RoglSlEr )'0" ar.:cess code Irom the fllJrll ~I ,.,... book 111
www.lItj ..... slngkltcorn.
LEARNING OUTCOMES
LAXATIVES pagt611
1"1"1)
Saline and Osmotic f1llt6J]
Stimulant pa;t 6]]
Stool Softener/Surfactant ".611
Herbal Agent pi1jt 611
ANTIOIARRHEALS fIIJ9IW
Opioids paJt 614
..
Indicated.
4. Explain cond iti ons in which the ph,umacotherllpyof nausea and
vomiting is indicllted
5, Describe the types of drugs us.ed In th e short-term management of
obesity.
sown
AHnMETICS , .619
prochlorptf(J~ (Cotnpttl.hf)
pagt6JI
ptl9t6Jf
PAHCREATICEHZYM(R1PlAUMlHT
{IfI1t6J5
Q JlClfIUf~ (CO(Ozym.I'I,",cr..,~
6.
OlhMJ ,.,636
KEY TERMS
anoroiam pI19t6JI
antifmttic pogt 619
bodymassindu(BMI)
Cilthilltic pqgt6}1
~6JI
d'of1norH@!ItOltriggtfzone(m)
UlIlSIipation ".6]1
ptl/t6J8
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fJI'1t61S
l~iltOlthta fXl}t6JS
ukefatitulliitis p;gt615
620
41 .1 Normal Function
of the Lower Digestive Tract
The lower portion of the GI tract consists of the small and
large intestines, as shown in ,. Figure 41.1. The first 10
inches of the small intestine, the duodenwn, is the site
where partially digested food from the stomach, known as
Duodenum:
reoeOY85
chyme
I""" stomach
Jeiunum:
perlo"",, most
01 digestion
andchemic.al
absorption
"
"':,"""5
material
I"""small
inlesti""
,. Flgure41. 1 The digestive system:functlons of the smallintenine and large Intenlne (colon)
Source: Pf'a00fl fduwtion/PH CoIleqe.
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''''''lfr 41
PHARMFACTS
Gastrointestinal Disorders
Uktrati'lt rolitis 1m a peakOII!H from agts 15 to 30 and anothrrfrom
aljH60toSO.
k. many <IS 40'!1. ofthOlt <Igtd 6S and older repln I"NIJrTfnl (onllipation.
Irritable bcrftl ),ndroru alftcts 10% to lO% 01 adults.
Am .... itans sptnd m~than $ll billion anfll);ll~ 011 OftightffdKtion
products and srrvim.
Thr in(idtlKt 01 motiolsic:knm ptab from ~ 4 to 10,and then
~illStorll'f:li~.
GalistOll~s auoontforW'lb 01 all Qlf"lol oKutf pan(lNtitis, whr~as
akohol (OIIIUmption iU!I;ociaud with 70% 01 all drronic: panm'atitits.
About lS,*, of Americans (m~ than 1 million adults) who all.' using
Wl'ight-losssuppll'melRl a~ oot Oft lWI'ighl
CONSTIPATION
Const ipation is a decrease in thf frequency of bowel movements. Stools may become dry, hard, and difficult to evacuate from the rectum without straining.
41.2 Pathophysiology
of Constipation
As waste materialtr;;vels through the large intestine, water
is reabsorbed. Reabsorption of the proper amount of water
results in stools of a normal, soft-formed consistency. If the
waste material remains in the colon for an extended period,
however, too much water will be reabsorbed, leading to
small, hard stools. Omstipation may cause abdominal distention and discomfort, and flatulence.
Constipation is not a disease, but a symptom of an underlying disorder. The etiology of constipation may be related to a lack of eJ{ccise; insufficient food intake, especially
insoluble dietary fiber; diminished fluid intake; or a medication regimen that includes drugs that reduce intestinal
motility. Opioids, anticholinergics, antihistamines, certain
antacids, and iron supplements are just some of the medications that promote constipation. Foods that can cause
constipation include alcoholic beverages, products with a
high content of refmed white flour, dairy products, and
chocolate. In addition, certain diseases such as hypothyroidism, diabetes, and irritable bowel syndrome (lBS) can
cause constipation.
The normal frequmcyofbowel movements varies widely
among individuals, from two to three per day, to as few as
one per week. Patients should understand that variations in
frequency are normal, and that a daily bowel movement is
nOI a requirement for good health.
Occasional constipation is self-limiting and does not require drug therapy. lifestyle modifications that incorporate
increased dietary fiber, fluid intake, and physical activity
should be considered before drugs are utilized for constipation. Chronic, infrequent, and painful bowel movements,
accompanied by sewre straining, may justify initiation of
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621
laxatives
laxaties are drugs that promote bowel mo~ments. Many are
available over the counter (OTC) for the self-treatment of
simple constipation. Doses of laXlitives are identified in
Table 41.1.
41.3 Pharmacotherapy
with Laxatives
LaXlitives promote the evacuation of the bowel, or defecation,and are widely used to prevent and Ireat constipation.
Cathartic is a related term that implies a stronger and more
complete bowel emptying. A variety of prescription and
OTC products are available, including tablet, liquid, and
suppository formulations.
Prophylactic laxative pharmacotherapy is appropriate following abdominal surgeries. Such treatment reduces straining or bearing down during defecation- a situation that has
the potential to precipitate increased intra"abdom.inai, intraocular, or blood pressure. In addition, laxatives, in conju nction with enemas, are often given to cleanse the bowel
p riO! to diagnostic or surgical procedures of the colon or
genitourinary tract. Cathartics are usually the drug of
choice preceding diagnostic procedures of the colon, ouch as
colonoscopy or bariwn enema.
The two most frequt'ntly reported adverse effects oflaxa~
tivesare abdominal distension and cramping. Diarrhea may
result from excessive use. When cleansing the bowel prior to
colonoscopy or purging the bowel of toxic substances or
parasites, forceful, frequent bowel movements are expected
ou tcomes. Care must be taken to rule out acute abdominal
pathology such as bowel obstruction prior to administration because the drugs will increase colon pressure and possiblycause bowel perforation.
When taken in prescribed amOlU115, laxatives have few adverse effects. These drugs are often classified into five primary groups and a miscellaneous category:
,"
;;
,
o
622
Unlt7
Adwrse Effects
PO;llJfdaypm
methrl{du&ll' (Gtnnl)
BULK FORMING
calwm poI)Urbopbil (Equaiactin,Fibmon,
othfrl)
othfrs)
PO;lO~mUda,pm
STIMUlANT
bililodyl (Cor!tttol. Dukolax. othrn)
PO;IQ-I5mg/da, pm
PO;l5~mUdaypm
(CoDtt)
HERBAL AGENT
I
I
Abdooiool(fQmpirIIJ dQrrhto
Abdomioolaompirli dQrrhto
PO;8.6-171mg1da,
mintraloil
PO;I5- 30mLbid
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DIARRHEA
When the large intestine does not reabsorb enough water
from the fecal mass, stools become watery. Diarrhra is an inuease in the frequen'1' and fluidity of bowel movements.
Diarrhea is not a disease but a symptom of an underlying
disorder.
~ Prototype Drug
623
ADVERSE EFFECTS
~yllium is a wit Ial0tift and raft'iy prodlKf"I adl'l'nt efl~ts. k uu~ Itss
o:ramping than stimulant-type laxati~ and ""ul" in a 100ft' natural bowel
IIIO'/ tllll'Olll Liken with in,uflkitnt wate~ it IIIil)' (,lUll' obnllKlionl in the
tsophagusor inrestiOl'.
Contraindiu tions: Plyllium should oot bt idministertd to patient! with undiagOOW'd i bdominal pain,intf"ltinal obllruction,or Itul impauion.
INTERACTIONS
Drug-Drug: f'I)'IIi:.m maydKr&R tfwoaborptionaod fffem ofwarfarin,.n,
nitrolll"artoin. oIO~aod wkyla!fI.
lib TI5I!:~~um mol)' ioofil\o! tfwo IfIIIIO glwrlf Ilvel.
HerbaVFood: Unknown
PHARMACOKINETICS
Dn'tt: 12- 14h
Ptak: l- Jda)"5
HalfliM:Unmown
Duration: Unknown
LibraryPirate
disorders such as ulcerntive colitis, Crohn's disease, and irritable bowel syndrome can cause episodes of intense diarrhea.
Antibiotics often cause diarrhea by killing normal intestinal
flora, thus allowing an overgrowth of opportunistic pathogenic organisms. The primary goal in treating diarrhea is to
assess and treat the underlying condition causing the diarrhea . Assessing the patient's re.;:ent travels, dietary habits, immune system competence, and recent drug history may
provide information about its etiology. Critically ill patients
wilh ~ [",Ju~",J in""un" "'''1'''''''' whu ~r" =l'u"t:<I lu ''''Illy
Antidiarrheals
For mild diarrhea, OTC products are effective at returning
elimination patterns to normal. For chronic or severe cases,
the opioids are the most effective of the antidiarrheal agents.
The antidiarrheals are listed in Table 41.2.
41.5 Pharmacotherapy
with Antidiarrheals
Pharmacotherapy related to diarrhea depends on the severity of the condition and any identifiable etiologic factors. If
the cause is an infectious disease, then an antibiotic or antiparasitic drug is indicated. If the cause is inflammatory in
6 24
AdwrwEffects
PO;HOml~2hqidpm
loptramid!, (lmodiJm)
~mlqo:
MISCELLANEOUS AGENTS
bismuth sailS (Ptpto--BilmoI)
Im~ion,Rm'Sl~n~
~OIidf
(Saodostatinj
.!!mi!1!il
Irdla inditit~ common adl'mo! tffffis;lIIIkdi!iog, inditite strious adm~ tff~m.
~ Prototype Drug
Pharmacologic (lass:
~ioid
ADVERSE EFFECTS
Unlike most opioids,diplltnoxylal~ has 00 analgesic: proptni... and has an ntr~lIII'~ low pottntial foe abu~.Thedrug is'MlltoltruM at normal dous.Som~
palitnu apffiffi(~ diuines 01' drowsinffi, and t~ should oot driY<" 01' opt<ate muhilltr)' until tht ~fcts of tilt drug a~ known.
Contraindications; Contraindications include hypt~~tivity to th~ drug, s~
Vl'~ ~W'r distil~, obstructiW' jaundic:~, se'ItrI' dth)d ration or ~lKtrolyte imbalanc:~, narrow angl!> glaucoma, and dianhN aooc:iat~ with psrudollll' mbranous
wlitis.
ADMINISTRATION ALERT
INTERACTIONS
PHARMACOKINETICS
()twt 45-60 min
PmU h
Halfliff;H h
Duration; l-4 h
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Treatment ofllverdose; Dwd_with Lomotil may lit ltI'ious.Narrotic:i1ntagonim S!Kh as naloJ:on~ may readministl'rM par~nttrjl~ to rtVl'rII' rrspiruory
~prrssion within minute.
Rdtr IIIMyN/n1ngll (ora tmlniJl're\lFI/j~ IOI!ri! d'ug.
doses are available byprescription. Other OTC treatments in clude bismuth subs.alicylate ( Pepto-Bismol), which acts by
binding and absorbing toxin<;. Psylliwn preparation<; may
also slow diarrhea, because they absorb mrge amounts of
fluid, which helps form bulkier stools. Probiotic supplements
containing LactobaciJlus, a nonna! inll.1bitant of the human
gut and vagina, are S<lmetimes taken to correct the altered G I
flora following a serious diarrhea episode.
41.6 Pharmacotherapy
of Inflammatory Bowel Disease
and Irritable Bowel Syndrome
lnflammat~ bO'M'Idiseall! (lBD)
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625
apy for IBD. Entocort-EC is encapsulated to prevent signific..nt absorption in the stomach or duodenwn. The drug is
released slowly and reaches a high concentration in the terminal ileum and proximal colon, the two most frequently
affected sites for lBD. Thus, the drug is in direct contact with
the GI mucosa and, in effect, it produces a topical antiinflammatory effect. In addition, when it is absorbed,
bu desonide is almost entirely removed by first-pass metabolism in the liver. Thus, this drug shows few of the adverse
effects seen with the long-term use of other corticosteroids.
It is approved for mild to moderate Crohn's disease.
The introduction of biologic therapies in the btt 1990s
gave clinicians another valuable tool in the pharmacotherapy of lBD. The tumor necrosis factor (TNF) inhibitor infliximab ( ~miaJde) has been shown to effectively reduce
acutt symptoms and provide maintenance therapy for both
Crohn's disease and ulcerative colitis. A second anti-TNF
dr ug. adalimumab ( Humira) , was approved in 2UU7 for
Crohn's disease. ~cently, a pegylated TNF inhibitor, certolizumab pegol (Cimzia), was approved that offers dosing
at 2- to 4-week intervals. Natalizumab (Tysabri), a drug previou>ly approved for multiple sclerosis, was approved for
treating Crohn's disease in 2008. The biologic therapies are
ex pensive and patients experience a much higher rate of serious infections due to their immwlOsupprer.sive actions.
Biologic therapies are currently recommended onl)" when
corticosteroid therapy is unable to control symptoms.
lrritabl ~ bowel syndrom! (lBS), also known as spastic colon or
mucous colitis, is a common disorder of the lower GI tract.
Symptoms include abdominal pain, bloating, excessive gas,
and colicky cramping. Bowel habits are altered, with diarrhea alternating with constipation, and there may be mucus
in the stool. IBS is considered a functional bowel dimrder,
meaning that the normal operation of the digesti,e tract is
im~ired without the presence of detectable organic disease.
It is not a precursor of more serious disease. Stress is often a
p recipitating factor along with dietary factors.
Drugs used to treat IBS do not alter the course of the disease and, in some cases, they may actually worsen patient
symptoms. Research has not denlOnstrated that drugs are
any more effective than nonpharmacologic treatments such
as lBS support groups, relaxation therapy, or dietary changes.
There is not prototype drug for this condition. Drugs that
p rovide symptomatic relief for some patients include alosetron ( Lotronex), dig.domine (Bentyl), and hyosCYJmine
(Anaspaz, others). Tegaser<XI (Zelnorm) was once cOn<;idered a prototype drug for IBS but the United States and
Canada have suspended marketing of the drug due to the potential for adverse cardiovascular events. Drug therapy oflBS
is targeted at symptomatic treatment, depending on whether
constipation or diarrhea is the predominant symptom.
NaUIO!!l
"
"
Asseu ment
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InstllKt th~ palil-mto "II for ' lSistan~ prior to gening oot ofbed or
attempting to w. Ik alone if diuiness or drowsiness ocQJr.1'roYide
(ornmodl' or IItdp.n ne<llbjo. For hoIIII' u ~, .wid driYing or other miYi1ies
lfqUiring memal a!trtnes, or physic.i lcoordin.nion until lilt effK1S of lilt
drug a~ koown.
InstllKtth~
Tea{h tht p.;Itil-nt to like lilt drug as ordered ind oot 10 in{lNsr thedose
orfrequency un!t1S instructed to do 10 by tilt lItalth (III' provider. Arr;
df"OWlinm. dizzinHS, or dilOnrnmion should lit prompdy II'pontd to the
proYider.
,,,,,I
Th~ pilil-nt, family,orwtg~r should lit i b!t to ,tall' tilt ~'lOn for tht
drug; appro pRatr dose nd scheduling; whllt adYfr~ effects to oblerie for
and when to II'port; .J nd the antici pattd length of medication tiMorap)'.
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627
62 8
I Sulfasalazlne (Azulfidine)
ADVERSE EFFECTS
The most frt~t ~d~ efiKtl of suHasalaziot aR' GI-R'lated: nausea, rom
iting. dianbtJ, dyspepsia, and abdominal pain. DiYidi09 tht total daily dOlt
tvl'nly throughout tilt day and using the entericooattd labirn may impro~
adlltR'OU'. Hrad,ullt is common. Blood dyscrasia! occur infreqUtrltly dJri09
thera~.Skin rash",art R'lat~1y common and may ~ a sign of a mort I!'rious
a~~ efFIsuch u 5tewns- bhnsoo syndromt. The drug may impair mJit
fMility, which revmtI when tht dlllC) is discoolirAlfd. SuHasalaziot (in caust
photostnsitMI)'.
Contraindications: SuHaS.Jlazi~ is ooMraindiuted in patient! with sulfon
amide c.- salicylate (a Ipirin or S-ASJ,) hyptntrllitiYity. Patient! with plH'urung
J ntmia, folatt,or othtr htrn~tologic disordm should uIt tilt drug with (iutian
btcau I!' it may wontrl blood dyscrasia!. Sulfasalazint should be ustd with (iUtion in patients with IItpatic impairmtM btcaust tht drug (in (iUSt IItpalo\OJicity.Thf drug isconrraindica\l1d in palieotswith urinary obstruction and should
bt wd with (iulion in dehydrated patients becaust it may caUl!' crystalluria.
Puients with diabttfs or hypoqlycfmia shook! USt !U1f~ wlazint with (iutian
btcaultthe drug can incR'ut insulin I!'crrtion and worwo hypoglyctmia.
ADMINISTRATION ALERTS
INTERACTIONS
t:rug.Drug: SlililSaWiM IOa1 'M)I';I'n bcrw IllimlW IUppmion cawd by
rnrthourulf and aso R'SUt in ~itivf hfpato!~~. Ab:Iorpiion of digoxi1 1Oa1 bt
dPcR'a\.td. ~ can displacr warfarin film its p-Olein ~nd~ ~eI, IiII11i1g
iOONlfd anocoaojlNnt tIKI!.
Lab T~ts: lktoown
IkorbaVFood: Wfasalamr IOa1 dtcmN tht absorption of.OI1 and lOtic Mid.
Trratment of OYerdose: Overdose will calllt abdominal pain, anuria, drowsi
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abdominal organs, inner ear disorders, and diabetes. Psychologic factors playa significant role, as patients often become nausealed during periods of extreme stress or when
confronted with unpleasam sights, smells, or sounds.
The nausea and vomiting experienced by many women
during the first trimester of pregnancy is referred to as
morning sickness. If this condition becomes acute, with oontinual vomiting, it may lead 10 hyperemesis8r1lvidarum,a situation in which the health and safety of the mother and
developing baby can become compromised. Pharmacotherapy is initimed after other antinausea measures have proved
ineffective.
Nausea and vomiting are the most frequently listed adwrseeffects for oral medications. The nurse should remember that because the vomiting center lies in the brain, nausea
and vomiting may occur with parenteral formulations as
well as wilh oral drugs. The most extreme example of Ihis
occurs with the antineo p lastic drugs, most of which cause
intense nausea and vomiting regardless of the route they are
administered. The capacity of a chemotherapeutic drug to
cause vomiting is called its tmetogtni c potential. Nausea and
vomiting is a common reason for patients' bckof adherence
("",If,41
Antiemetics
Drugs from at least eight different classes are used to prevent
fMusea and vomiting. Many of these act by inhibiting
dopamine or serotonin receplors in the bJ"3in. The
antiemetics are listed in Table 41.3.
41.8 Pharmacotherapy
with Antiemetics
A large number of ~nli~m~ti<> are available to I,",,~I n~usca and
vomiting. Selection of a particular agent depends on the experience of the health care provider and Iht' cause of the
nausea and vomiting. Patients seeking self-treatment can
fmd seVt'r~1 options ~vail~ble OTe For example, simple
nausea and vomiting is sometimes relieved by antacids or
diphenhydramine (Benadryl). Herbal options include peppermint and ginger, the most popular herbal therapy for
nausea and vomiting. Relief of serious nausea or vomiting,
however, requires prescription medications. Patients receiving antineoplastic drugs may receive three or more
anti emetics concurrently to reduce the nausea and vomiting
from cht'motherapy. In fact, therapy with antineoplastic
drugs is one of the most common reasons for prescribing
antiemetic drugs.
629
Antipsychotic Drugs
The major indication for phenothiazines relates to treating psychoses (chapter 17010 ), but they are also very effective antiemetics. The serious nausea and vomiting
associated with antineoplastic therapy is somt'limes
treated with the phenothiazines. To prevent loss of the
antiemetic medication due to vomiting, some of these
agents are available through the 1M, IV, and/or suppository routes. Nonphenothiazine anti psychotics that have
high antiemetic activity include haloperidol (Haldol) and
droperidol (Inapsine).
Corticosteroids
Dexamethasone (Deu.dron ) and methylpredni,olone
(Solu-Medrol) are used to prevent chemotherapy-induced
and postsurgical nausea and vomiting. They are reserved for
the short-term therapy of acute cases because of the potential for serious adverse effects.
Other Antiemetics
Aprepitant (Emend ) is the first of a new class of antit'metics, the neurokinin receptor antagonists, used to prevent
nausea and vomiting following antineoplastic therapy. The
benzodiazepine lorazepam (Ativan) has the advantage of
promoting rela.ution along with having antiemetic properties. Cannabinoids are drugs that ,ontain the same active
ingredient as marijuana. Dronabinol (Marinol ) and
nabilont' (Cesamet) are given orally to produce antiemt'lic
effects and relaxation without the euphoria produced by
marijuana. Dronabinol and nabilone are Schedule II controlled drugs.
On some occasions, it is desirable to srimulatetht' vomiting reflex with drugs called em~ics. Indications for emetics
include ingestion of poisons and owrdoses of oral drugs.
Ip"~~<, ,ymp, giv~n ur.dly, ur ~puII1urphin", giv"n ,ub<.ul~
neously, will induce vomiting in about 15 minutes.
OBESITY
Antihistamines and Anticholinergic<
These agents are effective for treating simple nausea, with
some being available OTC. For example, nausea due to
motion sickness is effectively treated with anticholinergics
or antihistamines. Motion sickness is a disorder affecting a
portion of the inner ear that is associated with significant
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Obesity is a growing epidemic in the United States: II is estimated that 95 million adults are overweight or obese. This
represents 34% of the adult population over age 20. Obesity
is dosely associated with increased health risks that indude
premature death, hypertension, hyperlipidemia, diabetes
mellitus, heart disease, sleep apnea, and osteoarthritis.
6]0
TABLE 41 3 I S@I@ctedAnti@metics
Drug
Adverse Effects
diphmtl)'i"amilH' (Btoadryl,OIhm) (~
(Ii9C m for III!: ProtOl)'pC: Drug IJoxOOj
PO;25--loo mg lid-qid
,,",dli~(An~'Ifft, Broil~OIhm)
(!liCfIOIomiMJ
H'!IItIXOIiti'l~yru(\ion ICdatiQl). IrtmOf\
!!i&ur!j, hallu(iIa!mm.1!!!oooxiuJl ~)[(~ation
ImO!! (ammon in d1ihRnl.hypo!~nIiQl)
BENZODIAZEPINE
knlfpilm (Ati'l~) (~pilg!' 158 for tilt
Protot)'Jlt Drug boJ:OO)
lJzzjnm,d~lII<Di4 ~/igrIf,wrrrd5pM1l
CANNABINOIDS
drooabilol (Marinol)
nabilon ~ ((~m~)
I1HhlDo,~lmSOryQWQrmm
""""'"
CORTICOSTEROIDS
dex.imt1ha1oot (DeYdron)
PO;O.l5-4mgbid-qid
OIhfn)
rnpoUdwormdhf06l1g,mtmffiJol
I1boomrQ/irits,irn:mnio
!'Wi!: u~r.hyplK.ll(tmia.ostNQ9l1l5i! with
~Ol~~~ I!!!:!!lloour~ Iosl of mm mas~
dl'W'il!'d!lOW!h jn dtUdrro ool'jjblr milkjng
Fati~ID~5lipofion,dilrrl!to"Q~ rnlUlf4
hkrup
PO;8-16mgbid~id
prodtlorptruilt l(ompil1i~)
PO; 5- 10 mg lid-cjd
proolfIllil:iM (Phmtrgal,othm)
""",m.
E!;tral!):ramidal !)'!!!R!!!!!Th!m!~!k
maiiooant syJI!tpm!: aqilOuosytosis
di<lrrlilo
IlvIrIri!bmjaj QmqrumjdalwmptQmj
G/ldinsron (Zolrin)
PO;(mg~dpm
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""'<t<.
1ItoiIocM,~~ faligut,lDmripo~on,
~ Prototype Drug
63 1
I Prochlorperazlne (Compazme)
PHARMACOKINETICS
Onstt:11>-40 min 1'0;60 min Il'<IaI
Iflk: Unknown
Halflife:Unknown
Duration: H h 1'0 or rectll
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ADVERSE EFFECTS
Proc:hlorpmzint prodlKtS doIt-lt"Iated antic:holilK'rgic: side efftru wc:h .. dry
mouth, sed.nion, (on ,tipation, orthostatic hypotrnlion, and tac:hyu rdw. Wllto
UIfd for prolonged periods at higher dole, extr.pyramidal symptOllll ~m
bling thOlt of Parkinson', distalt all' <I SfriotK Olll(t m.
Contraindications: Thisdrug mould not beUlfd in patientswith hypt~miY
it)' to phenothiazi~, in (omatolf p.tients, or in tilt prtIfII(f of profound CNS
depIl'Ilion.h is allorontraindiuted in(hiidren )'OUogerthan age 2orwrighiog
lei thin 20 lb. Patients with narrow-angle glalKOma, balK' marrow Illppmsion,or ~ hepatic orcan:li imp-aifOlfnt lhoold oot t.~ this drug.
INTERACTIONS
Drug-Drug: Prodllorptiam. ilterat:s with aIat.oI aoo other OIS dfpIl'IloIfIts to
YUII' idditi'll' stdaIion.Antalidland .arlidi.!rlOOl:lilhibitthlo ib!ptiln of
p-ochklrpHazine. 'MItn tabo with ~erdlarbitat mttaboIiIm of p-odiIorpKazilf ~
inoNIfcLiM with tricydI: arlid@prrnanumayp-Olixtifl(rNlfdilltidiolinflgir:
.-.:IlIypoteflli'll' fflKII.
li biests:Untnown
HerbillFood: Unknown
TfNlmem ofOvtrdose:Overdose mavresuk in seriousCNSdefjlffiiM and ex
trapyramidal signl. Patienu m<ly be tll'~ted with amip-an.insonilm drugs (for
91rapyram idal S)'III ptOIlll) and poIlibly a CNS Itimulant sIKh .. dextroamphet
amint.
for losing weight, but few are patient enough to wait an entire year to lose a single pound.
Therefore, to lose weight one has to expend more calories
than one conswnes.Although nutritionists disagree, in terms
of weight loss, the sollrre of the calories (ca rbohydrates, proteins, or lipids) does not matter. Of course, the source is indeed important in terms of overall health and wellness.
Hunger occurs when the hypothalamus reoognizes the levelsof certain chemicals (gluoose) or hormones (insulin ) in the
blood. Hunger is a normal physiologic response that drives
people to seek nourishment. Appetite is somewhat diffurent
than hunger. Appetite is a psychologic response that drives food
intake based on associations and memory. For example, people often eat not because they are e:q'eriencing hunger but because it is a particular time of day, or because theyfind the act
of eating pleasurable or social. This is a key concept because
blocking hunger sensations with drugs does not guaramee
that a person will have less appetite or oonsumefewercalories.
Nonpharmaoologic strategies should always be attempted
before initiating drug therapy for obesity. This is true for two
reasons. First, drugs for treating obesity produce only modest results and should be taken for only a few months. For
someone who needs to Lose 25 or more pounds, nonpharmacologic strategies must be employed. Secondly, maintaining an optimwn weight C<lnnot be accompLished by drugs
alone: Smart lifestyle choices are required. A sustainable,
healthy diet and an appropriate exercise program are essential to losing weight and maintaining optimum weight.
Asse ssment
Re-.itw medications, foods, and the plssibilil)' of illnesl with the patient,
family, or (all'gr.er to help idtntif)' UUl.lliYe factors.
tk<ll'aM' noxiou Istimul i(e.g., strong odors, rapid (hange in position) that
m.Jy ill(~i5f naUM'a orvomiting.
Teac:h the patient to take the il ntiffnetic btfo~ tra~1 ij IIiIlIIN iI antici~ted.
If drowsifll'is or diuillfll milY O(rur, enrourag!' the patitntto (onsider a"tria I
run"with the medication tlken in t'lffiing btfoll' btdtillll' to il\{fruin
elite!> priorto tlking ifdriving illl'quift'<i.
Teac:h the pat~nt on i\homl'(hl'm01heril py to take antiemeUa prior to
dtemotheraP\' dost or routintly al ordtrrd b)' the heahh (ilft' provider.
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PIl!SIUI1'..)
InstnKt the patitnt to all lor uSist'lKt priorto gttting out of btd or
atttmpting to wi11k .1oM if dizziness Of drow~nts.I 0111'. PJOYide iWI
tmts.is hilin neilby.m homt Ust,awid driYing or other .tMties
rtqIIiring lllfIIul.lfrtnns Of ~ coordination untillllf rlffru of tltf
drugomknown.
hep.ltic~)
ImlnKt tire patifllt on thr netd to MthOOlcl tUds.wl food until vomitin9
h.s cused.fnitiatt illm'nk'IItal Ul1'aItS in intalt ~inning with srlliln
sips of wale. and dtit lIuids.
EqlIiin thr r.tiollillf lor illY IV hydrilion lequiftd and IllY equipmtnt
"""
The patient. fimil1.or calegiftr should lit able 10 mtt the reuon for the
drug;. ppropriate dose .nd !Chi!duling; 'llftit .eM 1st effu to obstrvt for
and when to reportand the .nticipattd Itngth of mi!diution theraPl'.
.1tiS.)
sma.
Tilt patient .nd flmily or tiI1'g~ are ,blf 10 disarss ,ppropMe dosing
alld administr"ion IIfflk.
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6]4
arc
PANCREATIC ENZYMES
The pancr eas secretes essential digestive enzymes: Pancreatic juice contains carboxypeptidase, chymotrypsin, and
trypsin, which are converted 10 their active forms once they
Sibutramine (Mendra)++
ADMINISTRATION ALERTS
Allow at Irolst 2WffIu belwel'n dilcontinuing MAO iohibitonand staning
siOOtramine,
Thisdrug is not approwd for !lSI' in patients undtr ige 16.
Pl!ijnancy rnegory (
PHARMACOKINETICS
Onset: Unknown
ADVERSE EFFECTS
Sibutlllmine is gentlllily 'MIl toIera\fd, The most smous aU;tlS!' ~f(ts '~ 01 ninmud risk of strou <I nd III)'OUrdial infaraion. HeadM:ht,coostipali:IO, ifllOmnia,
0100 RIOStomia oI~ tM mon common romplaims reporttd durilg ~butramifll'
thtrapy,Wtight gain may wr <lfter ~butramint ~ d~(OminUfd k ~ a Sditdur
lVdnrgwithlowpolentialfor~,
Contraindications: Sibutramint is (OIllraindiuled in p;ltitnts with eating disordtrs (.J llOmOa III'rvou or bulimiaj.Jnd thole laking MAO inhibiton. Tht drug
!hoold be Ultd "';th ca~ in p;ltitnu with he.Jn diseaS!',dysrhythmias,or ,Iroke
bmu ~ it mayUUlt tadtyurdii.Jnd raist blood prtSlUlI',
INTERACTIONS
I)ug- l)ug: lIstwith ~n,~,and atlH9Y lIIKkation, may<aUSf
Iflk:Uh
Half~ff: 14-16 h
Ik>rbaVFood:Unknown
Treatment of OverdoIt : Tach)'UrdY and hypenension m.JYII'IUk from omdost, BetNdrene"lic blockers may be administerrd
IWfI llIMyMlIbrgKJrflJf ~ MnlngI'reIJFoo/s~ 101M!tug.
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(IIIplfr 4t
~~A
reach the small intestine. Three other pancreatic enzymes---lipase, amylase, and nuclease-are secreted in their active
form but require the presence of bile for optimum activity.
Because lack of secretion will result in malabsorption disorders, replacement therapy is sometimes warranted.
41.11 Pharmacotherapy
of Pancreatitis
Pancreatitis results when amylase and lipase remain in the
pancreas rather than being released into the duodenum.
The enzymes escape into the surrounding tissue, causing inflammation in the pancreas. Pancreatitis can be either acute
or chronic.
Acute pancreatitis usually occurs in middle-aged adults
and is often associated with gallstones in women and alcoholism in men. Symptoms of acute pancreatitis present suddenly, often after eating a fatty meal or consuming excessive
amounts of alcohol. The most common symptom is a continuous sewre pain in the epigastric area thM often radiates
to the back. The patient usually recovers from the illness and
regains normal function of the pancreas. Some patients
with acute pancreatitis have recurring attacks and progress
to chronic pancreatitis.
Many patients with acute pancreatitis require only bed
rest and withholding food and fluids by mouth for a few
days for the symptoms to subside. For patients with acute
pain, meperidine (Demerol) brings effective relief. To reduce or neutralize gastric secretions, H ,-receptor blockers
such as cimetidine (Tagamet ) or proton pump inhibitors
such as omeprawle (Prilosec) may be prescribed. To decrease the amount of pancreatic enzymes secreted, carbonic
anhydrase inhibitors such as acetazolamide (Diamox) or
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635
L IFESPAN CO NSIDERATIO N S
H OME
&
C OMMUNITY CO NSIDERATI O NS
636
Unlt7 lheGo'ilrolnleStinalsym'm
ADVERSE EFFECTS
~IW rtrts of pn(~ip~ a~ unrommoo, sinct thr rnz)'llll's a~ 001 absorbed. Thr most frtqUrnl oIiMIW tife(ts an' GI symptoms of IliUll'a,wmiting,
and diarrllra .Vrry hi.;h doll'! 01 ~ moc:iated with a risk for hyptNricemia.
Contraindicationl: FalKrflip~ is (ootraindicated in patirnu allfl<JK to tht
drug or to pork produm. The delayed-nieolll' produru should not be giYm 10
pillitnu withoKUl\' pinae"'itis.
INTERACTIONS
1Wg- 1Wg: Porrnlipa;t inmru with i Ol1, whidlmay rflWi i1 dKrNSfd
absption ofiron.Nna:idI may~ the fife(! ofparmlipu.
lab Iflls: PanoripR rna, incrNlf \eIUm or urinal)' levels of uric add.
Ik>rbiollF.w:U" .......,
llNtment of Omdo~: High ~ of uric oIcid may oc:rur with o~rdoll'. Patitnts a~ UUled S)'ITplolNtiul~.
IIeI'lr III MyMnbtgl(l W ~ MnIrtg /'reIS Fo:us spKl/I( IIIIM <tug.
PHARMACOKINETICS
Ons!'!: Immediatr
Iflk: Unknown
Halflift : Unknown
Duration: Unkoown
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important poinls from the corresponding numbered section
within the chapter. If any of these points are nol dear, refer to the nu mbered section within the chapter for review.
41.1
'"
41J
41.6
41.7
.,.
41A
41 5
For simple diarrh~, OTC medications such as loperamide or bismuth compounds are effective. Opioids are
the most effective drugs for controlling severe diarrhea .
LibraryPirate
41.9
41.10 The pharmacothernpy of obesity includes the anorexiants sibutramine and the lipase inhibitor orlistat. Both
637
drugs are used for the short-term management of obesity but produce only modest effe.;:ts.
NCLEX-RNOREVIEW QUESTIONS
II
The nurse should educate patients to take diphenhydrinate (Dramamine) how long before tht")' board an airplane for a trip?
1. 20 to 60 minute"
2. ] 5 minutes
3. 2 hours
4. 6 hours
The nurse assesses for one of the major precipitating factors in the development Iss, which is:
1. stress.
2. peptic ulce!>.
3. gastroesophageal reflux disease (GERD).
4. Helwhamr pyillri.
II
1:1
The nurse has administered prochlorperazine (Compazine) to a p.1tient for postoperative nausea . Before administering this medication, it is essential to che\:k the
patient's:
1. pulse.
2. blood pressure.
3. IWlgsowu!s.
4. temperature.
EXPLORE
M)"flrsi1gKit i:s )'!lIlt OM :Itllp lor online cllapter t!!View mmriaiS an!l
resource .. f'f~are lor Sl.Uess WIth allditlOlll l ~LEX",slYl~ pracm;e
Ques1Ioos. InteractNe asslgnm(11!S (1'1(1 oc:IiV1tl!$, ~ 1I1ks. arMmatlorJs
~Ild "Id~OiS, and more!
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DRUGS AT A GLANCE
LEARNING OUTCOMES
Water-Soluble Vitamins
fCljt6-/l
;vge 644
MINERALS !'Jilt""
Macrominerals fOJt 648
Q lIl<lgne5Jumsulfote (MgSO.) P'X}t&19
Microminerals
pagtfA8
6.
KEY TERMS
miuornin~ral (tlll(f
beriberi f'Jt}t64J
rarote~
pI1Jt 641
paljt648
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minfral) nf,48
parenteral nutrition {!'Jgt6'lJ
IIfllagra JVjI f,43
IIfrnicious (rnfgaloblastid anf mia {tl~ 6-U
provitarnins fXl~ .39
Rf(omrnfnded Diftary Anowan(f (RDA) pagt&J9
SlJJrvy mrf,44
tOOlpheroi JXI9IfY/1
total parentrral nutrition (lPN) {!'Jgt651
undernutrition n65IJ
vitam ins pI1Jl6J9
ill
at'
VITAMINS
Vitamins are essential substances needed to maintain optimwn wellness. Patients having a low or unbalanced dietary
intake, those who are pregnant, or those exper iencing a
dlIoni~ di,,,,-~,t may bend;t from vitamin therapy.
LibraryPirate
639
.,...
640
TABlE42 .1 1 Vitamins
'D'
VItamin
Functlon(s)
Moo
1,0001119 RE*
Bwmpi9:bioIin
Cotnzy~
Wo~"
8001119 RE
qilr11XONbmin (Bul
~~,
lOnKg
,~,
,~,
1OO~,
16Q--1&Jmc:g
15-20mg
13-1Smg
..
/rom,nimaloric;jn
folic: ~id/folatr
(Bol
.xiii mriabolism
rioXin(BJ
ruction,
p.lntolheril:.xiII (8,)
pyridoJ:inflBJ
''''
''''
''''
1.H.6mg
ribo/IaYin(B,1
Cotnzyrnt in OIidatioo-frdJaion
U- l.8mg
1.HJmg
11- 1Smg
1.0-1.1 mg
ructions
ttiaminf (B,)
formation
Pr~oq,
C(aI(orbic:,dd)
,
,
60..,
~..,
S-10mg
>- 10mg
Antioxidant
IOTE**
8..,.
65-80m{lj
5>~5mc:9
m~lboIi<m
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Lipid-Soluble Vitamin,
The lipid or fat-soluble vitamins are ablUldant in both
plant and animal foods, and are relatively stable during
cooking. Because the body stores them, it is not necessary to
ingest the recommended amoWlts on a daily basis.
42.5 Pharmacotherapy
with LipidSoluble Vitamins
Lipid-soluble vitamins are absorbed from the intestine with
dietary lipids and ale stored primarily in the liver. \'/hen
conswned in high amounts, these vitamins can accumulate
to toxic levels and produce hypervitaminosis. Because these
are available OTC, patients must be advised to carefullyfollow the instructions of the health care provider, or the label
directions, for proper dosage. It is not unusual to find overthe-counter (OTC) preparations that contain 200% to 400%
of the RDA. Medications containing lipid-soluble vitamins,
and their recommended doses, are listed in Table 42.2.
Vitamin A, also known as retino/' is obtained from foods
containing (uot~n!S. Carotenes are precursors to vitamin A
TABLE 42.2
",,"
o wililmin
toc:opheml oonsli_
IUtes9O% of the tocopherols,and is the only one of pharmaoologic importance. Dosage of vitamin E is sometimes
reported as milligrams of alpha-tocopherol equivalents
(TE). Vitamin E is fOWld in plant-seed oils, whole-grain cereals., eggs, and certain organ meats such as liver, pancreas,
and heart.h is considered a primary antioxidant, preventing
the formation of free radicals that damage plasma membeam's and other cellular structures. Deficiency in adults has
been observed only with severe malabsorption disorders;
howtwr, deficiency in premature neonates may lead to hemolytic anemia. Patients often self-administer vitamin E beca~ it is thought to be useful in preventing heart disease
and increasing sexual prowess. although research has not
A(A~!Ol A,o:hm)
wililmin O:cakitriol(CiI:ijtJ:,
RocaKroI) III'~ p.lg ~ 735 lonh ~
ProIotypr Orugbox oo )
Adverse EffeciS
1IKl'1~f1
~n E:tocophrrol
POJlM;60-75 lII~slday
I'itlmin K:~ONdione
IAqwMEPHYTON)
""
~wm tff!'I:Il01f1i00llllll!00Olrwmmmdtddostl
H!!J!! dostS:rvYl!:'
LibraryPirate
vorni!i!!lf4!!!JI!!:,he'~ll!urmlmi2n
"'"
~, ~1iac
"
64 2
ADVERSE EFFECTS
Adft~ tfFeds art not obltlWd with norm.JI do~ of vitlmin A.Acure i~s
tion, howfm, prod!Kes serious CNS toxicir~, ilKUding ht ad<lrnt, irrirabilil)',
d"' .... illt'<~deli.i."n,.nd poibio mou. long_lmn i~<lion of high amrum<
UUIt! drying and scaling of tht skin, JIopia, fatigue, <Ir.orexi<l, wmiting. and
~1rDpen;'.
Contraindications: Vitamin Ain fllCffi of tht RDA is conrraindicated in Plfgnam parient\" or rho!!' who lIIiIy be<ome pll'gnanl Feral harm lIIiIy Il'IUIt.
INTERACTIONS
lWg- lWg: PI'opIt takill9litamin Ashould iMIid raki19 ninfral oil 0100
droil'll)'ramill@,bKall\!' both ma~ deouI,,1ht iIbIorpIiJn 01 vitamin A. (000I"i8l
II\!' with isorflinoin may lI!I,*in ~itift toxicity.
IkorbaVFoo:l:lJnknown
T~tment of OnrdoSf: The~ is no
Ouration:Unknown
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Water-Soluble Vitamins
The water-soluble vitamins consist of the B-oomplex vitamins and vitamin C. These vitamins must be conswned on
a daily basis because they are not stored in the body.
42.6 Pharmacotherapy
Adverse Effects
vitamin B,:thiamilll'
IVnM;~IOOmgtid
PonarirJjtioolile
PO:S 10mgfday
'tit.Jmin B,:ribolbvin
PO;HOmglday
NMfll
PO;ID-lOmglday
IV nMfsubcu!a1ll'OOl; 1,- 100 mg two to fiw tines/day
PonorirJjtioolilt
POIIMJlVI!lbrutantOUl;OA-1 mgfday
High ~~l:!!'!:l!!r!!!lmias
~r~
~lIl.diorrlil~
umalillia
/Jolin i"Ii"'I~ wn,"oo """""" "".u>;~i"Ii"'I" ...,.;""''''''''''''' .rr"'l~
Vitamin B" or thiamine, is a precursor of an enzyme responsible for several steps in the oxidation of carbohydrates.
It is ablUldant in both plant and animal products, especially
whole-grain foods, dried beans, and peanuts. Because of the
vitamin's abundance, thiamine deficiency in the United
States is not conunon, except in alcoholics and in patients
with chronic liver disease. 1hiamine deficiency, or berib~ri, is
characterized by neurologic signs such as paresthesia, neuralgia, and progressive loss of feeling and reflexes. With
pharmacotherapy, symptoms can be completely reversed in
the early stages of the disease; however, permanent disabilitycan result in patients with prolonged deficiency.
Vitamin B" or riboflavin, is a component of coenzymes
that participate in a number of different oxidation- reduction
I"C<Ictions. Riboflavin is abWldantly found in plam and meat
products, including wheat germ, eggs, cheese, fish, nuts, and
leafy vegetables. As with thiamine, deficiency of riboflavin is
most conunonly observed in alcoholics. Signs of deficiency
include corneal vascuLarization and anemia, as well as skin
abnormalities such as dermatitis and cheilosis. Most symptoms resoh-e by administering 25 to 100 mgldayof the vitamin until improvement is obserwd.
Vitamin B" or niacin, is a key component of coenzymes
essential for oxidative metabolism. Niacin is synthesized
from the amino acid tryptophan and is widely distributed in
both animal and plant foexlstuifs, including beans, wheat
,\\erm, meats, nuts, and whole-,\\rain breads. Niacin defi-
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Sea Vegetables
StJ v~gmble. or seawffd~ art J form of Il"IJrine algae th~t grow in tilt upP'" It.d. ofthi' O<e.ln, wh ... IUnlighl ron
wmpb ofthcs di
bit seawel'm inc:Udt spirulina, kelp, (hlo~lb, ararne, J nd nori, many of wh ic:h
a~ used in Asian rooking. SN 'le9!'tabirs art found in (oastallootions
throughout tilt world. Ktlp, or laminJria, is found in tilt (old watm of the
North Atbntit and P.J(ifirOmns.
Su I'f9I'labits (ootJin.J multitude of vitam ins,as WfII as prott in. Their moot
notabir nutritional asped. 110_, is thtir miooal (ootent. Plants from the
sea (ontain mo~ minerals than most other food SOUK6, induding (akium,
magnesilm, pllosphoroos, iron, potassium, Jnd all ffi~mial mc:~ tlrmtnls.
kause the, aft' so ric:h in min~rals, seawel'm an as alkalizen for tht blood,
helping to rid tht body of acid (ooditions (acidosis). Spirulina, kelp. and
(hlo~1a are a\\lilablt in IiIpsult or 1.1 blet form, or u pan of a'grrl'ns-minontaining other nutritiou Iingred~nts.
proo"."'.
644
PharmacologicClass: None
Folic: ~dd is administl'fl'd to rm'Be symptoJM of deficiency, whic:h most commonly occur; in patirnts with inadequate imakt, such as with thIOnic akohol
alxM.BecalMthis vitamin isdemo)'edat high tempemure~propltwhoover
coole thtir food may optrien~ folate dtIKirncy. Pl!9nallC)' marUdly inc~.ues
tilt nffil for dirtary folic: Kid; folic: acid is g~n during pregnane)' to promote
normal fetalgrowth.BeulQ inwfficient vitamin B" mates a lackof ~ctivated
folic: acid, deficienc, s)'tnptDmsll'lI'mblt thoW' of vitamin B" deficiene)'. Tilt
megaloblastic alll'mi.l obll'~ in folate--defic:ient patirms, howevrr, dor5 nol
inckidr tilt smll' III'IVOUS s)'Stem symptoJM II'tn in patienn with Bu dtficitney.Administration of 1mglday of oral folic acid ofll'n IM'rws the deficirncy
symptoms within 5to 7d.J)'S.
ADMINISTRATION ALERTS
ADVERSE EFFECTS
Adftlll' effects during folic acid tlltraP\' are uncommon. P~tirnu may f~1
flushrd following IV inition~ AIIt"lic hypmffisitivity to folic acid by tht IV
route is posliblr.
Contraindications: Folic: .Jcid is (onmindicattd in anemias other than th<M
caused by folall'deficirncy.
INTERACTIONS
I)ug- l)ug: ~Mn)lOll,trrnrthoplilll-~,iOilO!hfl lMliOOons may
Ik>rbaVFooo: lJnI;ncwn
Tll'atment of OYrrdose: The~ is 00 specific tlNlment ~r O'IeldoSl'.
PHARMACOKINETICS
Onset Unknown
P!ak: 30-1 min
Halflife: Unknown
Duration: Unknown
HOME
&
COMMUNITY CONSIDERATIONS
It is now well dorumtmed that low vitamin II. (folic acid) ~s in prtgnant
Womffi m.ly contribute 10 the formation of _fal tullt delecn in tilt feM.
Vitamin I\" or pyridoxine, oonsists of sewral closely related compounds, including pyridoxine itself, pyridoxal,
and pyridoxamine. Vitamin B6 is essential for the synthesis
of heme, and is a primary coenzyme involved in the metabolism of amino acids. Deficiency states can result from alcoholism, uremia, hypothyroidism, or heart failure. Certain
drugs can also cause v itamin B6 deficiency, including isoniazid (INH ), cycloserine (Seromycin ), hydralazine (Apresoline), oral contraceptives, and pyrazinamide (PZA). Patients
receiving these drugs m ay routinely receive B. supplements.
Ddj"it:ll"y "YJlJl'lull1s jllduJ" Skjll aUllufJlJalili,..;, d",ilusis,
fatigue, and irritability. Symptoms reverse after administration of about 10 to 20 mg/day for several weeks.
Vitamin &" more commonly known asfolateor folic acid,
is metabolized to tetrahydrofolate, which is e~ential for
normal DNA synthesis and for red blood cell production.
Folic acid is widely dis tributed in plant products, especially
LibraryPirate
green leafy vegetables and citrus fruits. This vitamin is high lighted as a drug prototype in this chapter.
Vitamin B", or cyanocobalamin, is a cobalt-containing
vitamin that is a required coenzyme for a nwnber of metabolic pathways. It also has important roles in cell replication, erythrocyte maturation, and myelin synthesis. Sources
include lean meat, seafood, liver, and milk. Deficiency of vitamin B" results in pernicious (mtgaloblastic! n emia. This vitamin is featured as a prototype drug in chapter 28 00.
Vitamin C, or ascorbic ocid, is the most commonly purchased OTC vitamin. It is a polent antioxidanl, and serves
many functions including collagen synthesis, tissue healing,
and maintenance of bone, teeth, and epithelial ti~ue. Many
consumers purchase the vitamin for its ability to prevent the
common cold, a function that has not been definitively
proved. Deficiency of vitamin C, or scurvy, is caused by diets
lacking fruits and vegetables. Alcoholics, cigarette smokers,
cancer patients, and those with renal failure are at highest
risk for vitamin C deficiency. Symptoms include fatigue,
bleeding gums and other hemorrhages, gingivitis, and poor
wound healing. Symptoms can normally be reversed by the
administration of 300 to 1,000 mgldayofvitamin C forseveral weeks.
MINERALS
Minerals are inorganic substances needed in small amounts
to maintain homeostasis. Minerals are da~ified as
macrominerals or microminerals; the macrominerals must
be ingested in larger amounts. A normal, balanced dil.'l will
Assessment
patitm will:
Review tlltdimry histo!)' with tilt ~tient and discusl food 1OUn:~ options
lor rormting anydelic:itlKits. [n(OlJr'ge th~ p,tient to adopt a healthy
lile\)'le of ilK ifilli'd l'<lriety in thediet.PlO'fide for dietitian (onsultation as
n~fdN.
RMew the dietary and supplemrm histofJ to (orrtct any o:~ting possibiliW
for hypervitJminosis and a~~drug rIiKh.(Ex{tSsil'f intakr of vitaminl
A, C, D,E. B" niac:in, and folic: acid may Itad to toUt ellto:ts.)
Oisrun the nrtd for nutritional rupplements if the normal diet is urwblt to
rupply these or if dista ~(onditions (e.g., pernicious aOl'lllil) Pll'Yfnt
ablorption or utiliz,tion.
Oiscourage tilt O'felllll' oIlUpplem~ntation and ptoYide information on
adverse rlfrmand symptoms relat~d to hypmitaminosis.
(conrlrruefi)
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64 6
InslnKt the patient 00110 takt IaIl1t' amoonu offat--solubif vitamins unlen
inslrumd by the health {ill' providtr.
En(ouliI~obtaining fat-1Olublr vitamilll from naM,1 !OUl{t"I sIKh I~
Vitamin A:. willis, pumpkin, winttr squa!h, rbrlc grten lrafyVl'getablts,
apricou, mtats, fish, and Imr.
Vitamin O:milk and other dairy prodIKU fonified with vilamin D,oiiy fi!h
(f .g., salmon, wrdilll'S), adrquate sun flpOSUII'.
Vitamin E:Vl'geIabkoiis <lnd ml l9ilrint"l marlr from egetabkoil!, fruits
and V!'9 r tabirs, grain~ nuts. ~rk, and forrified (tll'll!.
Vitamin K:gft'PlJl'fgtlabits SIKh IS turnip g~ns, lpinlm,{.1uliliower,
{ibbaoge and bro((oIi, and (fIlain vtgetabifoils induding !Oybtln oi~
{orron~ oi~{.1nola oi~and olive oil.
[nsurt Irlrqwtt hydration if Ia 191' dosts of water -1Olublr vitamilll III' takrn.
(Water-solublr vHamilll an' not slOlI'd in the body but III' "mtN.large
~ofvitamin ( nYy (iUIC rroal cal(uli.)
En(OUra~ tilt patitntlo in{lNst fluid imakt 10 llof lkJid pI'I" rby,dil'irlrd
throughout therla)o.
bound to organic molecules such as hemoglobin, phospholipids, or metabolic enzymes. Those minerals thai function
as critical electrolytes in the body, most notablysodiwn and
42.7 Pharmacotherapy
with Minerals
LibraryPirate
Adverse Effects
"' ~ I
91a1\oIWit~
mma
CALCIUM SALTS
calci!lll oKrtalr (PhosLo)
PO; 1- 29 bid-tid
ulci!lll dlIoridr
IV;o.S- 1.0g/q3days
PO; 1- 29 bid-tid
ulci!lllgllKonale (Kakinatt )
PO;I- 2gbid-qid
ulci!lllloKt.ltt (Cal-Lx)
IRON SALTS
ferrous fumarate
(FrosIa~othm)
PO; 325-600 ""1 qid; may br lJadually iflCll'a ltd 113 650 mg "d
aJ ~ and toitfatrd
poin,lfq(fQff1/Il(i'oo~
....
MAGNESIUM
mJlt!i!lll rhlorido! (Chlormlig. SIo- Mag)
flliCjllrli!lll hydfOJ(idf:lMilkof~)
CinlllIl!I:ilia !flRi[j)I~!X!.Jilulf
hypgltDljQll d ~ cp lrndQll Irl\eI )fWQjoo
[<ldal DirOlhtOO,wnkness
PHOSPHORUS/PHOSPHATE
poIiIs~Lm/sodium phosphail'J (K Phos original
lIvDtmhosR!!atl1llia ~ lBin,fr.Ktu!!l:,
mulde WN~n~; (QIlfusion
"NO
linr oKrtalr (Galm)
PO;50mgtid
linrgllKonail'
linrRMm (Oralinr,1inrate,O!Iim)
PO;IH1Omglday
NMrII1tfftrurn uocommooOI
fommfOOed 00JtJ
I immuoolUpprnion.aotmia
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648
Unlt7
42.8 Pharmacotherapy
with Macrominerals
Maaomineral, (major minerals] are inorganic substances that
must be consumed daily in amolUlts of 100 mg or higher.
The macrominera]s include calcium, chlorine, magnesium,
phosphorus, potassiwn, sodium, and sulfur. Approximately
75% of the total mineral content in the body consists of calcium and phosphorus salts in bony matrix. Re.:ommended
daily allowances have been established for each of Ihe
macrominerals except sulfur, as listed in Table 42.5.
Calcium is essential for nerw conduction, muscular contraction, ,onstru,tion of bony matrix, and h"llostasis.
Hypocalcemia occurs when serwn cakiwn fulls below 4.5
mEq/L and may be caused by inadequate intake of calciumcontaining foods, lack of vitamin D, chronic diarrhea, or decreased secretion of parathyroid hormone. Symptoms of
hypocalcemia involve the nervous and muscular systems.
The patient often becomes irritable and restless, and muscu lar twitches, crnmps, spasms, and cardiac abnormalities are
common. Prolonged hypocalcetnia may lead to fractures.
Pharmacotherapy includes calciwn compounds, which are
available in many oral salts such as calcium carbonate, calcium citrate, calcium gluconate, or calcium lactate. In severe
cases, IV preparations are adminislered. Calciwn giuconate
is featured as a prototype drug for hypocalcemia and osteoporosis in chapler 47CiJ1O.
Phosphorus is an essential mineral, 85% of which is
bound to calcium in the form of calciwn phosphate in
bones. In addition 10 playing a role in bone structure, phosphorus is a component of proteins, adenosine triphosphate
(ATP), and nucleic acids. Phosphate (PO.'- ) is an impor-
42.9 Pharmacotherapy
with Microminerals
The nine micromioerals, commonly called tra(f miouals, are required daily in amounts of 20 mg or less. The fact that they
are needed in such small amolUlts does not diminish their
key role in hwnan health; deficiencies in some of the trace
minerals can result in profound illness. The functions of
some of the trace minerals, such as iron and iodine, are well
."
Function
<al(um
800-1)OOmg
<h_
7. . .
magllelirm
Mffi:151>-4OO mg
Wornm:280-100mg
Corauor for many mzymf!; lIt(elSary for normalllfM oonduaion and muldt (ontrKlion
...,....
...
potJl~Lm
~
"".
700 ..
2.0g
"'''
HtCf"lSary for normal Om'! oondudion and muldt (ontraction; prindp.ll cation io i"ltriKtllu,r nuid; t5!fntial for
add-balf "nd dt(troIyt~ balitOO'
Ht"lsary for normal Om'! oondudion and muldt (ontraction; prindp.ll cation in utriKtilwr fkJid; t5!fnwt for
add-balf "nd dtnrolyu balitOO'
lIOIeIt"blilhtd
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IlI>pltl (l
Oruq< /0.
649
ADVERSE EFFECTS
ADMINlSTRATION ALERTS
Cootinuous~ monitor tM patitnt during IV infusion far NrI)- signs of de(It'aIe<i (,J rdiac: fuoction.
Monitor ~rum m'glltsium ~k mry 6 h during pa.t nlml infusion.
When gJYill91V infusion, gil' lI'quill'd doll' O'/ tr 4 h.
PlI'9n.ncymtgoryA
F PHARMACOKINETICS
On~t: 1 ~2 h1'0; 1 h 1M
f'eilk:Unknown
H. Iflife:Unknown
Duration: 1-4 h1'0;30 min IV
INTERACTIONS
Drug-Drug: lJ5f with fIl'II"OIIlI/IIUar bIodHl may iocJNlf J@ijIiaICJ)'dfpm.lion
olOd .~. eooo.Jl'OI!Mof ~withakoholor other CN, dtpil'!wnI'; may
INdtoilKlNlfd Ifdation. ~ sam may IiKJNlfw abIorption 01" rntain
",ti~nIKtim such;>\ t"'raqdi ...
lib Tem:UoUlolrm
Herba VFood: MagneWn sam may deauwo W abIorption of (fI~n am.
inflouiv5llKh ill mracydilf.
Trrat mt nl of Imrdos!: Strious rr-spiralary ,nd cardiac: supp~sian m.y reuk
from ol'ffllole. CikiJmglucOn.J~ or 91uctptatt m.y ill' .dministt red IV iI. n
.nlido~.
9t!fPr Ie M)M!I! IngIJ1 for Q Nlml"9 Pn:ms f/KJJ5 lpKlk Ie ,iris mlMrlI.
Tr.ce Minerai
'DA
.....
0.05 - 2.01119
0.1 ""9
dmnilln
"""
"'-
15 ~1.01ll9
ftuoriOl'
15-4.01119
;~
lSOmc:g
Men:lO-12mg
Worntn: 10-15 mg
.... ng.OI'"
2 -~
md""~
75- 2501119
Mtn:50-70meg
Womtn: 50-55 meg
12- 151119
ltim!lll
,.
""1
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650
UnliT
lheGisUolntfltl~lS)lstem
NUTRITIONAL SUPPLEMENTS
The nurse will enco unter many patients who are undernourished. Major goals in resolving nut ritional deficiencie$ are to
identify the specific type of defici ency and supply the missing nutrients. Nutrition31 s upplement s may be needed for
short-term therapy or for the remainder of a p;ltient's life.
"t
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GI d isorders
Chronic neurologic d isease such as progressive
d~phagia and multiple sd~ros is
Surgery
Trauma
The most obvious ca USC' for undernutrition" low di etary
intake, although reasons for the in3dequat e intake must be
3.'iSessed. Patients may h3ve no resources to purchase food
and may be suffering from starv3tiOn. Oinka l depression
leads many patients to shun food. Older adult patients may
haw poorly fitting dentures or difficulty chewing or swal lowing after a stroke. In termin al disease, patients may be
comatose or otherwise un3ble to take food orally. Although
the etiologies differ, patients with insuffident intake exhib it
a similar pattern of general weakness, muscle wasting, and
loss of subcutaneous fat.
When the undernutrition is caused by lack of one spec ific
nutrient , vitamin, or mineral , the d isorder is more difficult
to diagnose. Patients may beon a fad diet lacking ooly protein o r fat in their in take. Cenain d igestive d isorders may
lead to malabsorption of spec ific nu trients or vitamins. Pa lients may simply avoid certain foods such as green leafy
vegetables, dairy products,or meat produc ts, which can lead
to specific nutritional deficieocie5. Proper pharmacotherapy requires the expert knowledge atld assessment skills of
the nurse, and sometimes a nutrilional consul l, so that the
correct treatment can be 2dmin " t~ red.
CIIop1tr 42
"~.
DrugS /0,
Nut,ftloNl Olsolders
65 1
Assessm ent
Btitlint aiKliment prigrtgIdminlitrlllOl'l:
Undtnttnd the ~tiOO lilt drug hiS bttn p~ribed in ordtllD ilSSHS fol
thelilptUlic: tIIeru (t.g.. short- ollo"9'tetm thela~. undtllyu'o!l heillth
d~onlm).
o
o
o
o
{COIIrInutdJ
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6 52
Assess ment
Usr mid ilSl'ptK ttchniqur with all IV tubing or bag [hangr~ and sile
drrs~ng (hangrs. Relrigeratr thr TPN IOknion until 10 mirutrs !lfloft' using
ind st~ riIIlra emml formula in thr rrlrigerator alteropeoing. (Infusion
and ac:(rss ~tes ilrr at high risk fordtvtlopmrnt ofinieuion and must hr
monitorrd frr"",ntly. Soknions ,md mrafonnula must hr ft'frigeraltd to
inhibit baurri.llgrowth.)
Explain Ihr rationalr lor all drrssing and rquipmeol monitoring and (hangrs.
Te.Kh appropriatr lfihniqur (asrptic: or dun) to Ihr lami ~ or GI rrgil'l'r if
llllrition is to hr mntinurd at home, followtd by rttum demonstration umil
liM' lamily is (omfonable with the routine.
InslnKl Ihr patient on thr III'rd for frrqueot gl(l[OSI' monitoring.Tud! the
patirm, la mill', or Llrrgi~rr to IfIIOn signs of h)<pergl){rmia (mrssiYe thirs~
mpious urinalion, and insati.blt hungrr) or h)'poglyt:emia (nervousness,
initabilil~, and diuinm) promptly.
InstnKt tflr patieo~ lami~, or urrgiYer in thr tKhniqlK' to monitorupillary
gUmsr, IoIlowrd by rMUrn-demonstration, ij tiM' ))aIirnt will hr on nutrition
rrplai:rmrot at home.
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IlIopltl41
OruqslorNutr~"""'IO""rd<>"
653
Maintain a(ruratt ffit~ral feeding or TPN infusion rue with inMion pump;
m,ke "te change! gradwlly;<lnd avoid ,bruptly discontinuing TPN fffiling.
(Tht 1M of infulion pYmpl ,11ow! precis~ rontrol OY!'r ffitl'l,1 fe~ding rate or
TPN infusion. Abrupt discominuuion may Will' hypogiyttmia,and a sudden
(hangt in parffiteral flow rate !an Will' fkKtuations in blood gl(l(oS!' Iewoll.)
AlstSl for appropriate ffiteral rube ~emtnt btIore adminiltrriog ~ny
Explain the ratiolhlle for (heciing tube ~rllll'nt priorto m hiecdingto the:
patien~ family, oruregiY!'r.lfhol1ll' enteral therapy is ordtrtd, teoKh the
patien~ family, or ufI'giYl'l the appropriate m~thods ior(hecking pIoKffiIerlt
prior to fffiling.
...- 1
Patient unMrstanding of drug therapy;
US!' opportunititol during administration of m~diutionsand during
.!S!eSS/mtts to discUlS the rationale for drug therapy, ~fI'd the:rapMK
OUi(omtl,mOIi (ommon ad\'el!t tiftcts, p",metm for when to ull tht
hfillth Uft' proYidtr, <l nd any lIf(ffi,Jry monitoring or precautiom.(lhing
time during nursing !are helps to optimireand reinfon:e kqtu(hing <I fNI.)
Patient self.administrilt io n of drug thf ril PY:
Whe:n administtring the mtdiution,imtruu th~ patitont, f,mily,orureg~r
in the proper Sl'1f...Jdminismtion of the drug. ~.g., taken with addition,1
tkliIh. (PIQptr administration.an impWlt the tf'le(tireneHOlthedrugl.)
Tht p,titont, family,orwtg~r should lit ab~ to Stilte the fI',son for the
drug; appropriate dost j nd stlieduling; what advmt diem to ob!efYl' for
and when to rt'port; <lnd theantKipatN ~ngth of medication therapy.
The p,titont and f~mily or ufI'giver aft' ,bit to discussappropnate dosing and
administration nl'l'ris.
The patient, family,or.areg~r is able to ~rurn-dernollStrate appropriate
dosing. ,nd administration and mr of mtlssiltl ,nd IUb~s prior to home
us~.
-r- -
~~~" ~
therapy by confinning that ~titont goalland fXpKted OU\(om~ haY!' bten met (~"lanning").
Chapter REVIEW
KEY CONCEPTS
The numbered k")' con""pts provide a succinct summory of the importam points from the corresponding numbered """tion
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
42.1
421
42.3
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42.4
42.5
42.6
654
42.7
42.&
42.9
An older adult has been diagnosed with pernicious anemi3 and replacement therapy is ordered. The nurse will
3ntieipate adminislering which vit amin. and by what
lechnique?
1. B., orally in liquid fom}
2. K, via intramuscular injection
3. D, bylightbox therapy or increased sun exposure
4. B", by intramuscular injection
The nurse is assessing a p.1tient who is exhibiting general ired wrukness, cardiac dysrhythmias, hypertension, loss of
deep tendon reflexes, and respiratory distress. What could
be the possible cause of these symploms?
1. Hypocalcemia
2. Hypercalcemia
3. Hy}xlmagnesemia
4. Hypennagnesemia
II
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~-~'-----,
EXPLORE ~
MyNllrsing i'Jt is ywr COle $lOp for onHne CIlapw rl!w,w materialS and
re1iW1WS. PrOlKlle lor success MIll acJdiliOllilI tlCLEX"'-&t\4Il practiclt
UN I T
The Endocrine
System
CHAPTER 43
CHAPTER 44
CHAPTER4S
CHAPTER 46
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DRUGS AT A GLANCE
LEARNING OUTCOMES
1. [)@scribethegeneralstructureandfunctionsoftheendocrinesystem.
pIlIJtM I
4.
S.
6.
Glu(ororticolds p!JIJ'6J(J
Antiadrenal Agents
7.
fX1Y 611
10.
11 .
KEY TERMS
Addison's disuse fX1IJ'611
adenohypoph~is fX1J'657
G' . ... di
fII1!' 61IJ
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fIIl1'61O
[1JIJ'66J
IlIoplfl41
657
taneous control over a single muscle fiber or gland, a hormone from the endocrine system may affect thousands of
cells and take as long as several days to produce an optimum
response. Hormonal balance is kept within a narrow range:
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a. an integratedllni!.
An~erior
pHuilluy
.....
~~:~---f L_,~::~""1
Ad ..... lgland
Thyroid gland
Ii=>
G"."' . . . . ,GH}-/
Bone, mu.de,
ot.er ~iuues
,,,.,,"',,,,, ~ ~
......., .......
I
---~ Testo5Ieltlne
185105
Ovari...
,. Flgure.fl.2 Hormones associated with the hypothala mus and the pitui tary gland
Sour(/': PearsonEducaf/oo/PHCalege,
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Dopttr (I
A Ift",","rr
inf~nt
,hlor.mph~ni<oI
Hormolll'(s)
Dlwrder
Drug Therapy
Adrrnal lOft9
Gl<ocortiloid!
Hypmtmtion:UMiIl S)'!1dro .. ~
AntialRnal~1I
Hypostu~ion:Addi5on~di~
Qurorortiroirk
Piwilall
Growth honnon~
l/ypost(rtIion:Yl\a1 SliJture
Hypmtmlion:oKKIIl"ItO}Ily (adulI)
Ortrrotid!' (mdosLJtin)
.,...
An:idill"~ir hormonf
Hypost(rtlion:diabufS ~Ul
l\ypI'~ion:GrMs" di~a~
Hypostuelion:m)"ll~ (olduks)
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659
660
Adverse Effects
HYPOTHALAMIC AGENTS
octre01jdf, (~odo statin)
.......
pfgYiIorunt {Somivmj
linin
NaIl5tll,~rrfII4i~tcric:tJJilf!pain,flllfiktl~
L~r dilmag,!f'litrd nnloaminilt!MI!
roIYntropin (Cortrol)'ll)
(ushi!!!U~
lJIet.lsmnin (Inml9,lpluj
somatotropin (Aur~tropin,
Gffiotropin, H!lllittropt,
Norclitropin, tlnropin, Srrosim,
~ilrn,Zorbtil'f)
Ii
.
~
'j
Ug il:ligiIUItaIlll: lWiIlm
d6mopll'l~n (OOAVp'Stimat~ )
vasopm~n
hypolHlrtmii
rrtmor,pd~
mOil
MlmiriIg. WVrtrrtWllm
*Hyporhalimk and pil!ilirY ~u ultd forrondiTionsofTh~ ftmal~ fl'productiv~ S'f5lffil.r~ pr~T~ in mapler 45 00.
Irdla indit.lT~ common adl'ffSt ftf~m;lIII1Wili!III. indiciT61trious idm~ ftI~m.
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cm:inoid tumors. Acromegaly mayaiso be treated with pq0somant (Somavert), a growth honnone-receptor antagonist.
ANTIDIURETIC HORMONE It is essential that the concentration of fluids in the body be maintained within narrow
limits. Loss of large amowtts of water leads to dehydration,
whereas too much body fluid leads to congestion, edema,and
water intoxication. Antidiurrti( hormmr (ADH) is one of the most
important means the body uses to maintain fluid homeostasis.
As its name implies, AD H conserves water in the body.
AD H is secreted from the posterior pituitary gland when the
hypothalamus senses that plalma volume has decrealed, or
that the osmolality of the blood has become too high. ADH
acts on the collecting ducts in the kidneys to increase water
reabsorption. The increased amOlUli of water in the body
reduces senun osmolality to normal levels and AD H secretion stops. ADH is also called vasopressin, because it hal the
ability to constrict blood vessels and raise blood pressure.
A deficiency in AD H results in diabete insipidus (DI), a rare
condition characterized by the production of large volumes
of very dilute urine, usually accompanied by increased
thirst. Two ADH preparations are available for the treatment of diabetes insipidus: vasopressin and desmopressin
(DDAVP,5timate).
Valopressin is a synthetic homlOne that has a structure
identical with that of human ADH . lt acts on the renal col-
AOVERSEEFFECTS
~opmsin (an cau W'symptormofwater intoJ:ication:drowsi~~ hNdac:ht,
and listitlllll'ss, proejll'Ssing to (OIIl'Ulsions and (orna.Otlltr ~eflem indUlk transitnt lItadacllt, nauW'a, mild abdominal p.ain and mmping, facwl
llulhing, hypertension, p.ain, or ~Iing at injection site. Intranasal forms can
(aIM nasal (ongtltion, rhinitis,ind epistuis. Toltrancr oieYmpslO th~ e~m
of rlesmopmsin wilen it is administered rnorr frequtnlly than ~ry 48 hour;,
orbjotlll'lVroutt .
(ontraindi (ltions: Dtsmoprrssin is (ontraindicatl'd in p.atitnll with diabet6
insipidus that iscauW'd by 100111')' dilfiW' bmUW'thtdrug can WO~ !\rid rrII'ntion and o..moad It is uW'd with (aution in palitnlS with (oronary irtery disN il', hyptrtensiOll,and in p.atitnts al mk for hyponallt'mia or thrombi. Young
childrrn and thtolder aduhs should ~ trrut<! with caulion beciIM thm 11'1titnu <lit' mort' pron~ to wner intOlicalion and hyponatrrmw.
INTERACTIONS
Drug-Drug: lnarnfd antid~retic: oKtion can OU\I" with GlIbammpiIll',
(hlor[l~,dofibrate,and nonlleroidal iIl~~nllammator,OOigI IHS.I.IDsI.
OKlN5edan!i~ntKac:tion
epineptri~.
Li bTi51S:Unmown
PHARMACOKINETICS
On~:lmmt<!iale IV; I h PO
Prak: IHOmin 1V;4-7h PO
Halflift:75min
Duration: lh 1V;S-lO h PO
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HN VFood:Unknown
Treat ment of OVfrdOS~: Ov!'rdos~ may (,JIM W'Y!'rr Wilt r intOlication.Trratmtnl ilKludei water rrstriction and osmotic diJrrtKs.
662
o
e
"
NeUlOsecretDtY
cells ot hypothalatnl5
anterior
....
Neg"" ""
, "
THYROID AGENTS
Thyroid disorders are common and drug therapy is often
indicated. The correct dose of thyroid drug is highly individualized and requires careful, periodic adjustment. The
medications used to treat thyroid disease are listed in
Table 43.3.
o./
tncreased
metabolic .ate
Thyroid Disorders
Hypothyroidism is 10 times mort mmmon in women;hypenhyroidism is
Sto 10 times mort(ommon in women.
Tht two most (ommon thyroid disffil"l, Gram' disf.m and Hashimoto's
thyroiditis,art autoimmuflt disNm and may hal'f a gmetic: ~nk.
Ontof ~tf)' 4,000 babits is bom without a working thyroid gland.
About lS,lXHl new m!'i of lliyrOd can(ff <1 rtdiagnOlfd f<l(h )'eolr.
Ontof ",-,Iy fil'f womm oId~1 than 75 )'eolB has Hashimoto's thyroiditis.
Postpanum thyroiditis O((UB in 5% to 9%ofwomrn and may rtrul in
IutUrt pr!gnalKits.
Both hypenhyroidism and hypothyroidism can dfoo a woman's abtlityto
brcol1ll' pr!gnant and can calM miswriagtl.
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43.6 Pharmacotherapy
of Hypothyroidism
Hypothyroidism may result from either a poorly functioning thyroid gland or low secretion of TSH by the pituitary
gland. The most common cause of hypothyroidism in the
United States is destruction of the thyroid gland due to
chronic autoimmWle thyroiditis, a condition known as
Hashimoto's thyroiditis. Early symptoms of hypothyroidism
in adults, or m)"ftdrmil, include general weakness, muscle
cramps, and dry skin. More severe symptoms include
slurred speech, bradycardia, weight gain, decreased sense of
taste and smell, and intolerance to cold environments. Lab
0""
Adwrw Effects
THYROID AGENTS
dtsir:Gilttd th)fOid (ArInoII', 8j,). Thyroid, ThyKid
Wtiglrrloss,lrtodhf,~
usp'othtrs)
mo~htorinroltrooce,
IlnrIMbmjal byptOernioo
PO;2>-75 mOJlday
ANTITHYROID AGENTS
m~himu. (lapuol~ )
PO;H,mgtid
NilUltll,rasI!.prurilrJ~ Wl'i9hrgoirr,
hfadochf, fm! oomblltSJ in /ingtfJ,
lftj~dklfrOOl
SSK~ Thyro.8Iod:)
propylthiouracil (PTU)
lidioacti~
PO;300-450mqtid
PO;O.s-150 mG la Gor (I.-it iu lI"I~ oflidioa.ajy~,)
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uals with myxedema coma. The short duration of action allows for a rapid responst' to critically ill patients.
Serwn TSH levels are used to evaluate the progress of
therapy. Because small changes in drug bioavailability can
affect thyroid function, patients should avoid switching
brands of medication once their condition has stabilized.
V-Ihen initiating therapy in older adults, the precaution is to
~SO low and go slow,~ because there is a risk for inducing
acute coronary syndromes in susceptible individuals. Replacement therapy for most patients is continued lifelong.
ANTITHYROID AGENTS
Medications are often used to treat the cause of hyperthyroidism or to relieve its distressing symptoms. The goal of an
tithyroid therapy is to lower the activity of the thyroid gland.
43.7 Pharmacotherapy
of Hyperthyroidism
Hypersecretion of thyroid hormone results in symptoms
that are the opposite ofthose caused by hypothyroidism: increased body metabolism, tachycardia, weight loss, elevated
body temperature, and anxiety. The most common type of
hyperthyroidism is called Graves'd ilrase. Considered an autoimmune disease in which the body develops antibodies
against its own thyroid gland, Graves' disease is fourto eight
times more common in women, and most often occurs between the ages of 30 and 40. Other causes of hyperthyroidism are adenomas of the thyroid, pituitary tumors, and
pregnancy. If the cause of the hypersecretion is found to be
a tumor, or if the disease cannot be controlled through
pharmacotherapy, surgical removal of the thyroid gland is
indicated.
664
Unlt l
PHARMACOKINETICS
On""l: 3- 5 I" (ordl), 24 to (IV)
Pea k:3-.4 wk
Half~ife: 6-7 cia)'!
Duration: 1 ~3 wIc
ADVERSE EFFECTS
Attlltlil peutKd=s, adl'ffSe ~Is oflewthYlOJ:ine tlltr~ py a~ ra~,~ hhough
U~ must he taktn to avoid OYertnoatmt nl Ad"mSl' tl~cts a~ thOSl' of hyperth)oroidism and inc:lude p;llpitaDoos, dyvhythmi.l~ ~ruo:itry, iOlOlllnia, weight
Ios~ and h~at intolel1lKf. Men!tnJal irR'9ulariti~s may OC{lJr in hma~ and
Iong-tt nn U\I' 01 ImIthyroxine !ws bft>n aslO(i.lied with osteoporosis in
women.
Contraindications: l.tfOthyroxine ~ contraindKatfd if t~ patient ~ hyperSl'llsitive to the drug, ~ optril'lKiog thyrotoxKosis, or h~s sel'm (ardioval(ul~r
conditions or arute lIl)'ocardial inlarrtion (Mil. If gmn to p;ltitnts with ad~MI
insu/frc:itncy, th)'Jllid hormone may (~lM a serious ~~oa krisis; thus, the insufficiency should bt {ometed prior to ~minimation of Ievothyroxine.1i should
he ulofd with (aution in pa~nts with urdiac: dM~ SI', h)optnt osion, oIdtr
~duhs, and impaimi kidney function. Symptoms of di~bttH mellitus ma)' bt
WOMned with ~min~mtion of thyroid hormone ~ nd dole of ~ ntidiabttK
dlllCJS may ~ui~ ~justmtnt. L.ewthyroxint has I bIad boJ warning t!wt it ~
illl'iftctift for wtight miudion and can bt potrotially IOIK wlltn ulofd with
~nom:tK drugs.
INTERACTIONS
"""""ion
smous
in
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pT<'8n~nl
pati .. ot.<.
AH,u m, nt
~t fU:I 'kIIImf
DUrrhea
DdirrdGrowtb.nd~
SitwlioNlLow SeIf..s1mn (INttd II MigI1c, ~1U!t)
Impairtd lIrinary EimiNtion (nortumll mmis)
Dmmt~(drugtbmpy)
Thf patitftlwil:
~ tbelJpMK ffff<U (t.g., height nc'tilt ftlNlI,nblr owrtinP,ciI.mii daM we wftind strUm omoIility witbin IIOIINIIimiu,teIUIft II
normll bowel fI.mion, lIOCtumil t1UM IIol:S SID\IPf).
~M'fm.n.Ofnpmm;t min_~tftu..
Ymilirr In undfl\lindirlg of the dN(s 1I\t,~ tftu.and ~ p~.
Dnnomtmf p~ 1fI'1dminim-1rion of tile ~tion (t.g.,dost,m. .... wh~n II noIif1 pro"YicIrr).
Impl ementation
Intervention s and (Rational e s)
Ensuring tMrlpNtk ftfffiS:
PoritnIJ fIltinggrowflthormotlf: Monito! ~iIjIl iOO weight II 00 {~nical
visil.Repor\ Iict of groowth tothe llN~h (irt p~.(~k of groowth ,tiff
a jlfliod 01 mm~tent grllWth m11 matt tht dffllopmtnt 01 antibodifs
again! GH.)
PatitntJ rQkinggrowflthormOllf antQgmjsn: Monitor ,"tis of strum GH.
Monitor boweIlOUrm 1M for 1dtcrt11t in dianht,.(GH ,nugon~ts art
giwon for acromfgi t" Itwort di1nhN un respon ~wo to other drug thmpy,
and the trtatmfnt 01 portal hyptrtension.Monitoring levtlsof strum GH
and bowel iKlivitywili n , IU11t tilt'1pwtK(h,ngts.)
PotitntJ tQlirll}lII1tidilJrrti( homllNltS: for Pit~rrts"";th diabet~ imipi.:M,
monitor urineoulpul,uriflt 100 strum osmo"lity,100 urint sptcifio: gr,vity
for In/m 10 nonnallimits. 1f gi-ltn fo, OO{~ enuresis.h,'/f tilt patient,
f,mily,o, U"9Mr Rtp 1 diM)' of sIttp patWIll, noting any btd-wrlting.
(Urineoutpul,osmolilit); and SIItlifK grirty should 'twm to norm,l ~mits.
W-tMg has)(owtd or slO9ptd.1
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won.
""'" """'"
666
Unlt l
IMtnKt the p.atifnt on thr IIfI'd to ft'lUm periodKally for lab work.
Tra.c:h thf diabetK!)at~nt to monitorypillal)' gkKOI~ IMIs m~
frtqUl'ntl~ during therap)'. Replrt an~ {onsistrnl Mvillion s in blood
gkKosr to the health (art provider.
.~~
[valua1l' the efflM-III'SS of drug therap)' by [onfirmiog that j).IIitnl goals and rxpKltd outlnH'S ha~ ~n mt! (s~Planning1.
5tf ~4J. l & l ,rorQIiIr!tutp III wIir~ rheltIlllMgocOOns~.
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propylthiouracil) to manage thyroid storm. Potassium iodide (Thyro-Block, ThyroSafe) is administered to protect
the thyroid from radiation damage following a nuclear
bioterrorist act, as discussed in chapter 300.
43 .8 Normal Function
of the Adrenal Gland
Weighing only two-tenths of an ounce, each adrenal gland is
divided into mu major portions: an inner medulla, and an
outer cortex. The adrenal medulla secretes 75% to 80% epinephrine, with the renlainder of its secretion being norepinephrine. Adrenal release of t'pinephrine is triggered by
activation of the sympathetic division of the autonomic nervous system. These homlOnes are described in chapter 1]00.
667
The adrenal cortex secretes three classes of steroid hormones: the glucororticoids, mineralocorticoids, and gonadocorticoids. Collectively, the glucocorticoids and
mineralocorticoids are called corticosteroid5 or adre,lOcortiC<lJ hormones. The terms corticosteroid and glucocorticoid ue often used interch~ns""bly in clinical pr~ctice.
However, it should be Wlderstood that the term corticosteroid implies that a drug has both glucocorticoid and mineralocorticoid activity.
GONADOCORTICOIDS
The gonadocorticoids secreted by the adrenal cortex are
mostly androgens (male sex hormones), though small
amoWlts of estrogens are also produced. The amounts of
these adrenal sex hormones are far less than the levels secreted by the testes or ovaries. It is believed that the adrenal
gonadocorticoids contribute to the onset of puberty. The
adrenal glands also are the primary source of endogenous
estrogen in postmenopausal women. Twnors of the adrenal
cortex can cause hypersecretion of gomdocorticoids, resulting in hirsutism and masculinization, signs thai are more
noticeable in females than males. The physiologic effects of
androgens are detailed in chapter 4600.
I Propylthiouracil (PTU)
ADVERSE EFFECTS
DYl'rtreatllll'llt with propykhiool"iKil prodlns s)'lllptams af hypothyroidiml.
Ruh ,nd tramitrn lwropenii Ul'the most frequent j(jYffit I'ffKlS. Asmall
peKrnt'9t ofpatitnunptritrK~ iljrinulocytosis, which ~ its mosl serious 1rJ..
~ rilKI. Periodic Iabol1ltary blood (ounts and ISH value '''' rte(rsS.J ry to rsublish proprr~.
Contraindi (iltions: Propyithiourj(ilshouid not lit giYen during pll'9nancy or
Ij(tltion or to p.ititnts with koown or wspeard hyplthyroidism.
ADMINISTRATION ALERTS
Adminillerwith m!'"luo rrduc:r Gl d~tlffi.
PlI'9nillqutrgoryO
INTERAalONS
Dru;rDru;!: Prop)1IIiooool MHlf'i1hf iCIionI of antk~ whidi ~ri@I
ill OONIfd r~t of~dirlij.lodilf..l:on1iining iHj@flts ~iocIironf, potaIsiOOl
1CJIjdt, lOdium 1OIidf) and U,roKIlIcrnIJnts (0)11 naqooill' tIIf ~KIi_s 01 tIJS
dlllg.(IM~~ya({\Ir;"abou(~of)lil1ifntswhohiwf~i
PHARMACOKINETICS
Onset: 30-40 min
Iflk: 1- 1.5 h
Halflife: I- 2h
Duration:1-4 h
HerlJiIVFood: Unkncwn
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~Wl.
Treat ment of Overdou: Dvt-rdosr will WM signs of hypothyroid~m. T,e"'IIIfIIt indudfs a thyroid igtn~ "'ropilll' far brad)Urdia, ,, OOS)'lll ptomuic: tll'iIIIIfIIt as III'(rssary.
668
Unlt l
Assessment
Activity IntoteranU'
FatigUl'
Constipation
De~t Knowledgf (drug tht r.lP,)
Riok for Infedion (1I'1attd to aomllfdrug effeds)
""""
Aslffi for adYmr t!ff,m: nilUSN, VOln iting, diarrlltii, tpigastrK distres~
skin rillh, it(hing.lltadoKlIt, umymdia, palpitatiolll,dysrhythmial,
S"M'ating. nervotJllIl'IS, par6t~sias, tll'moJ1, in !Omnia, lItat intoleranc:t,
and angilY.Hyp~ CH hyptntnsion, tac:hlUrdia, 6 pt(iillly mooattd with
angina, \hoold bot II'pOntd immtdiattly.
Planning ' Pati .. nt Goals and Exp ..cted Outcom ...
----II--
AdYilfthe patient that tht drug will help to ltabililf thyroid hormone
Itvtls quKkl~, but lull t!ff(l\ maytakt a Wffkor longer toocrur.
InllnKt tilt patient to maintain (OOsistfOt doling during this initial period
to illiow t~drugto ft'ac:h thtrapeutic: Itvels.
InslI\Kt the patient 10 Wl'igh ItH t'NOto thref time! per Wl'ek and to
record t~ puhe rate.Bring tht lI'(ord of Wl'ight and puhe to eath provider
visit.
Monitor diet for iodinf<onta ining foods (e.g., iodized salt. roy sall<f, tofu,
109ur~ milk, llrawberrie,. tggs). (inuf,l\ing CH dt(ft'aling normill iodint
intake may ft'IUlt in ad'lme drug fflecll.)
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TN(h the patient that lInilll dail)' ilOOUilionl may o((u~6pf(ially ruring
ptriod\ of Itrffi or illlIl'Is.Any signifKilnt or inc:reilling d\a09fl in pulse
rate. weigh~ IIl'I'IOUlnes CH fitigut, intoltriln(e to heit CH {Old,.! nd
diant.ea or (onllipation should lit II'pOntd to tht lItilkh (aft' prOYidet
Monitor for signs of inlKlion, (Be aocl platelet (aunK (Antithyroid drugs
ma, talMaogranulocytomJ
Instruct the !)at~nt to I!'pon I_r, ra!he~ SOIl' throa~ (hills, malaise, or
weakness to the lItahh (1ft' provmr.
Tea(h tilt patient aocl family or Uft'9Nrr that the lawnt doll' will ~
staned and graruilly in(ft'.tII'<I to fiocl the optimum ie\'el. Arr$ signirK.lot
chan~ in symptoms should ~ Il'portl'd to tilt IINlth care provider
prompd,.
-
[n!llft' !)at~ nt !<IfN)" rspecially in older adulu. Ol!sere lor diuin~SI aocl
monitor ambulation until tilt rflem olthr drug aft' known. (Dizzilll'SI may
~ 5f(oocIaf)' to (hanges in pIIl\t or blood ~!uI!'. Efircu of thyroid
hormonr on bone l\'IIlodeling II\a)' piau the !)at~nt at risk for frmu~J
Instruct the !)atienl tocall for mistalKe prior to ~ning 0lII of bed or
atll"nlpting to walk alone if dizzifltllO({II~
Assess tilt salety of the h~ environment and distun modifK.llions that
mi)' be IIffiIed with tilt lamily "ft'9il'l'f.
Trich tilt patienno limit wotan with fjmily to I hour perday per person
until the tl!'atmenl period is ~r. Young mildrrn aocl PlI'9nant WOflK'O
should avoid (Onia(\.
Advise the patienl to ifl{lNsr fluid intau and 10 void fre~mly to ,wid
irradiation 10 gonads from radiomil'i!)' in the uriIII'.
Instruct the !)alieni oot 10 expedorat~ and to co~r the mouth when
<oughi"'l.AnyconllmiOlt.dti....,. !hauld b< dispoord of pert .... protocol
of tilt hNkh carr provider.
al!'i~)
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6611
670
MINERALOCORTICOIDS
Aldosterone a.:COWlts for more than 95% of the mineralooorticoids secreted by the adrenals. The primary function of aldosterone is to regulate plasma volume by promoting sodiwn
reabsorption and potassiwn e."tcretion by the renal tubules.
When plasma volume falls, the kidney secretes renin, which
results in the production of angiotensin II. Angiotell'lin II
then causes aldosterone secretion, which promotes sodiwn
and water retention. Attempts to modify this pathway led to
the deVl'lopment of the angiotell'lin-oonVl'rting enzyme
(ACE) inhibitor class of medicatioll'l, which are often preferred drugs for treating hyperteru;ioll and heart failure
(chapters 23 and 24 00). Certain adrenal tumors cause excessive secretion of aldosterone, a condition known as hyper~1d05teronism, which is chm"lKterized by hypt'rtension and
hypokalemia.
Circadian rhythms
51.......
~
; -.
Hypolha1am.J5
e
(
Negaliva
Ioodback
GLUCOCORTlCOIDS
More than 30 glucocorticoids are secreted from the adrenal
cortex, including cortisol. corticosterone, and cortisone.
Cortisol, also called hydrocortisone, is secreted in the highest
amount,and is the most important pharmacologically. Glucocorticoids affect the metabolism of nearly every cell and
prepare the body for long-term stress. The effects of glucocorticoids are diverse, and include the following:
_ Increasing the level of blood glucose (hyperglycemic
effect) by inhibiting insulin secretion and promoting
gluconeogenesis, the synthesis of carbohydrates from
lipid and protein sourv;es
_ Increasing the breakdown of proteins and lipids and
promoting their utilization as energy sources
_ Suppressing the inflammatory and immWle responses
(chapters 32 and 33 00)
- Increasing the sensitivity of vascular smooth muscle to
norepinephrine and angiotell'lin II
_ Increasing the breakdown of bony matrix, resulting in
bone demineralization
_ PmmOline hmnc.hnclilMinn hy making hmnc.hial
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e
Adrenal corlex
G', ""'
Biological ellocto
51imulalion ~
Nag&live
tee<lba.d<.
!!!!!!)It-
GlUCOCORTICOIDS
The glucocorticoids are used as replacement therapy for patients with adrenocortical insufficiency and to dampen inflammatory and immune resporu;es. The glucocorticoids,
listed in Table 43.4, are one of the most widely prescribed
drug classes.
671
0""
AdverSE' Effects
Sodumltluid rtr~_,
/JClN',lIllier~iIsomll4 mood
SHORT ACTING
{OItisoo~
INTERMEDIATE ACTING
meth)'lprtdni!Ol~ (~M~roI.Med'oI,othtB)
prrdrilOloM
LONG ACTING
dwlMihalOlle
IM;O.HlJl9lday
ll+irlql,iOCltllml~pptrilf,
weighrgoill, fD<i~llIrIlIif1l}
knNirtdwwnd h~)ling,
!N1kinq of ink(\iom.~lmai
aU!lI!hl h~~mi.!,l!mil:
YRn gl.:!IKOOU OID'ppormjl
musd( w)S1i!IIJlMablrn.
CHF
'IIOOffling of
mrrn,
"""""
43.10 Pharmacotherapy
with Glucocorticoids
Symptoms of adrE'norortical insufficiE'ncy include hypoglycemia, fatigue, hypotE'nsion, incrE'ased skin pigmE'ntation, and GI disturbances such ~s anorexia, vomiting, and
diarrhea. Low plasma cortisol, accompanied by high plastrul
ACTH levels, is diagnostic, because this indicates that the
adrenal gland is not responding to ACTH stimulation.
Primary adrenocortical insufficiency, known as Addison's dis~as!, is quite rare and includes a deficiency of both glucocorticoids and mineralocorticoids. Autoimmune destruction
of both adrenal glands is the most common cause of Addison's disease. Secondaryadrenocortical insufficiency is more
common than primary and can occur when corticosteroids
are suddenly withdrawn during pharmacotherapy.
When glucocorticoids ~re taken as medications for prolonged periods, they provide negative feedback to the pituitary to stop secreting ACTH. Without stimulation by
ACTH, the adrenal cortex shrinks and stops secreting
endogenous glucocorticoids, a condition known as adrenal
atrophy. If the glucocorticoid medication is abruptlydiscontinued, the shrunken adrenal glands will not be able to secrete sufficient glucocorticoids, and symptoms of acute
adrenocortical insufficiency will appear. Symptoms include
nausea, vomiting, lethargy, confusion, and coma. Immediate administration of IV therapy with hydrocortisone is essential, as shock may quicldy result if symptorru remain
untreated. Acute adrenocortical insufficiency can be prevented by discontinuing glucocorticoids gradually. Other
possible causes of acute adrenocortical insufficiency include
infection, trawna, and cancer. The development of adrenal
atrophy following corticosteroid administration is shown in
Pharmacotherapy Illustrated 43.1.
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. Adrenal insufficiency
Allergies, including allergic rhinitis (chapter 38 00)
Asthma (chapter 39 00 )
Inflammatory bowel disease, including ulcerative colitis
and Crohn's disease (chapter 41 00 )
Edema associated with hepatic, neurologic, and renal
disorders
Cancer, including Hodgkin's disease, leukemias, and
lymphomas (chapter 37 00)
Transplant reje,tion prophylaxis (clJapter 32 00)
Rheumatic disorders, including rheumatoid arthritis,
ankylosing spondylitis, and bursitis (chapter 47 00)
Shock (chapter 29 00)
Skin disorders, including contact dermatitis and rashes
(chapter 48 00)
672
PHARMACOTHERAPY ILLUSTRATED
43.1 Corticosteroids (Glucocorticoidsl and Adrenal Atrophy
1.
Norm~1
a d"'nal glat>da
...,,'"
following cortioasloroid
Gmd",,1 Discootinuation
3. Gmdual withdmwal ot
cortico<;teroids allows adrenal
glands \0 ""SUllie normal
tunction
Sudden Discontinuation
4. Suddan wilhdmw ot
corticosteroids I....ds 10 awe
IKire nai insufficiency
' hypot_ ion
lethargy
",,,,,Itailura
asthenia
""u"""""""'mog
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43 .11 Pharmacotherapy
of Cushing's Syndrome
(u~ing's syndromr occurs when high levels of glucooorticoids
are present in the body over a prolonged period. Although
hypersecretion of these hormones can be due to pituitary
o..pltl43
673
Event
Description
mmun~ ~
Supprrs!ion 01 tilt immu~ Jnd io/lammatory mporlltS ilK/UltS pa~ftlts' IlJI(tplibility to ioftaions. lhrir ao~-ilnammatOlY
actions may!M II:: till' signs 01 an o illilg infection,
i'rpIi(!HtrS
..""""
DtYelopmmt of ptp~1 ukm ~ Q(ul',rsptdaliywhtn oombilll'd with nonsttroidil aolHnflammatory drugs (NSAIDs).
Bthavioral d1angtS
Pt)'thologit man~!MY til' nin, W JlntI'/OIIIIlrn or moodilll's~orm~ i!1l'Ol'l t halliKNtiom and OONttd lliddal
ttndmdrs.
EytdlanlJl's
Metabolit d1an~
Thn h)'IIffiJlytffilit tfka railtS serum ghKOII' and can caU\e ~!KOII' ilt~~I~. Mobilization 01 lipids nwy uU\e ~pffiipidtmii
and abnormal lat dtposit~ ElKIrOI)'It mangtS indude h)'pocakffilii, hypobltnia. and hyptmatrrmia. ALid r~l!'n~on, W!ight gail,
StllKturaliy idtmi loll with tile naturJ IoormoOl' (ortilo~ hjdrocortisoot is a S)Tlthetic corticOSlrll)id that is the drug of cMKr for liming adrtnocortia I insuflidenC)'. When !Md far rtplaten1ft1l therapy, it is givrn <II physioklgit doltS.
Oll{~ properdoliog isoKhirYfd,its th~rJpwtic: rlfrmshould mimic:t~ofen
dogtnous {ortitosttroitk. H)IIrocortisoot is abo iYJilabit for tile U~atllll'nt of
inflammation, allelijit disordtB, and mJny olhtr londitions.lnuNnic:ular injtaions mi y br givt'n to dtcrull' St~rt inflammation in all'Itd joints.
Hydrotonilone is available in YJ diftrlt'Otlonoulations. HjdrotoniloOl' bu
(kr=b-HC, Alp/mit no, (('latOn, oillen) and hydrotortilo~ oKetatt (AnUlOI
HC, Cortaid, Conti' Au-Iatd ar~ iYaiiabit as oral plt'pafations,~Jms, and oint1III'On. HydrotortiwlII' typiona1l' (Contl'FkJid) is an oral SUlptnsion. Hydrotortilon~ todium phosphate (Hydf\XortoOl' Phosphalt) and hydrotortilo~
todium I!Ktina1l' (A-Hydf\Xor~ So/uumtfj ar~ for pa'~nttral USt on~.Hydro
(ortisOIll' vaitfal~ (Weslron) isoniy far topital applitations.
ADMINISTRATION ALERTS
ADVERSE EFFECTS
Wh~n UIfd allow dom for reploK~menltherapy, or b)' tile topital or imranasal
raft. HoweYt~ ygrrs of Cushing'l
synd,allll' un dev!'lop with high dOltS or with prolongtd ulI'.lf taktn lor Iongtr
than 2 Wl'tks,hjdf\Xortisoot !hould bedisrononurd graduil~.Hydroc:onilolll'
posltSm IOIIlt milll'lalotonic:oid Jctivity,w todum and fluid rttention may be
ooted.A widt ratH}!' ofCNS Hfern hom been rtporttd, ilKUling insomnia,ilUiety, huda{lIe, ~rtigo,conMion,and dtpression. Card'lOYaI(ular tliecl'l mJ, indude hyperlension and tathlUrdia. IlIng-ltrm therapy may resuh in peptK
uk~rdMJse.
Contraindimions: Hydf\Xonisone is loolrainditaltd in jlitirnu wha alt' hyperwnsit~ to th~ drug or who have known inflion~ unless tilt patirnt is bring tr~att<l lonrun~mly with imi-iniettives. Patients with diabrtH,
OIteoporolis, psyo.:ho~ Ii'm' dis9I1', or hypothyroidism shoo Id br tJNtt<l with
"ulian.
INTERACTIONS
PHARMACOKINETICS
Antitl'd~agt'OlSmay~Ie'II'R'II'flkneII.~ma,caul4'
~k: lhPO;4-8hIM
Halflife: 15- 2 h
Duration: 1- U days PO or 1M
H~ VFood: lII4'''
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Assess me nt
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Tl'ilCh the patient how to monitor the pIIM and blood prt5MI~. [nsurt' tilt
proper lilt and lunctioning 01 any home equipment obtliMd.lmmedi~teIy
~n tichyurdia, palpitations. or ilK~ilstd BP to th~ heilkh ure pro'Iidtr.
67 5
Monitor for signs and Iymptoms of inreuion. (Corticosleroids rupp Il'II th!o
immune and inflammatory Il'sponm and may mask thesignl 01 inreuion.)
--+-~
Monitorfor osteoporosillt.g., bonedenmy testing] periodic.Jl~ in patienll
on Iong-ttrm (Of!i<osttroids. ElKourage adtqwte "kium intakt, al'OidalKt
of wbonated sodas,and wflght-bearing nen:~. (Corticosteroids alft
bone mttabolilm and mol)' GlIM osteoporosis i nd "'dull'!. Weight-bearing
I'J:trtM st~1e bont ind tll(ourages normal bone Il'modeling.Extesi'll'or
long-term (onlUmption 01 taroonattd sodas has bn linked to an ilKll'a5ed
riskoiostNpo!OIis.)
Wtigh tht patitnt daily and It'pOn wtight9'lin or in(lming peripht ral
edema. Me.!IUft' the inti kt and output in the hOlpitalill'd patient. (Dai~
weighl is an rurate mNSUll'of fluid status <l nd tlkts intoi((ounl intlkt,
outPU~<lnd inll'nsible IolmJ
Instruct the patientlowtigh leifdaily, ideally at III!- I<l~ li~of day.TII!patitnt should It'pOn a wtight gain of moll' lhan 1kg (approximately lib)
in i 14--hour ptriod or more than 1 kg (approlimate~ 4-5Ib) ptrWffk,or
in(ll'asing periphml tdtma.
Do oot stop til!- drug abrupt~.Tht drug nlJst be laptll'd off if LISI'd longer
thiln 1or 1 Wffks.(Adll'nal insulfitienq and (rM may o((ur with prolound
hypoten lion. ta(hyurdill, and othtr <ldYtr>e efi11 if drug is Itopptd
abrupti)oJ
T~ath the
Implementation
Inte rve nti o ns and (Rati o nale s)
Tht ~tient fjmii)o,or rall'gim should br jblt to state the 1l'<l lOn for the
drug;appropMt doll' and sc:heduling;whilt ,d"/rBl' tlfts to obSl'lVl' for
aod whtn to Il'poI"t thtm;and t~antitipattd length of ~ication
therapy.
Til!- ~titnt and fjmi~ or urtgivtr all' <l ble to disc:uss appropnalr doling
and administration nttds,ilKluding:
Take drug in tht morning at the Silmr time toKh day.
Take drug with food, milk,or a medlto prtVeIlt GI upii'!.
HOlMhold measuring deWe suth iltralpoorlldilfer signifiunti)o in
sill' and amounl and should not bt UItd for pediatric: or liquid dosrs.
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676
Unit. Thl'ElIdoalneSym'm
43J
43.4
43.5
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43.6
Hypothyroidism may be treated by administering tbyroid hormone agents, especially levothyrol ine (T. ).
43.7
43.8
The adrenal oortex secretes glucocortiooids, gonadocorti, oids, and mineralocorticoids. The glucocortiooids mobi lize the body for 10llg-term stress and influence
ca rbohydrate, lipid, and protein metabolism in most cells.
43.9
NCLEX-RNOREVIEW QUESTIONS
2. Hyperthyroidism
3. CUshing's syndrome
4. De>dopment of acromegaly
3. Growth homlOIlt'5
4. Antithyroid hormemes
When administering hydrocortisone (Cortef, hrdrorortone, others), the nurse reaJglliz.es it may mask which
symptoms!
I. Signs and symptoms of infection
2. Sigrul and symptoms of heart failure
3. Hearing loss
4. Skin infections
2..
CiftU~tory 0lIbpse
3. De>dopmentorOlshing's~
4. De~ntofdiabetesimipid\lS
What preoullons should a patient who Is receiving radioactive iodine be made a....'areoi'! (Select aU that apply.)
I . Drink plenty tt fluids, espeda1ly thost- high in alldum.
2. A\"OId dose c:ont3ct with chOdren or prtgnanl women
for 1 v.w:k aftendminlsl ration of the drug.
3. Be aware of symptoms of tachycardia, increased
metaboU, r~Ie. and anxiety.
4. v-.wa mask if.round children and pregnant women.
5. Signs and .>ymptoms of hypothyroidism indude general
weakness. muscieaamp&. anddty skin.
A patient with diabetes insipidus has stabilized but will be
discharged home on d('$mopressin (DDAVP, Stimate) by
nasal spray. When admInistering d('$IJlospress.!n intranasally. aU of the IOUmring administration guidelines
should be followed EXCEPT:
I . gently rotate tbt' nasal spnty bottle bel"orespntying but
do noIwke.
2. store the bottle at room temperature but avoid uc:esslve
heat over 80" F3. SPIllY the nasal spray high into nasal cavity, avoiding tile
bad: tt the throat.
4. usc the spray each morning at the same time of day.
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J. A 9-year-old boy has been diagnosed with growt h hormonedefkiency. His puents havededded to proceed with
a presalhfd regimen of somatotropin ( Humatrope).Out]jne the basic information the parents need to know reguding this regimen, side effects. and evaluation of
effectIveness.
Su Apprnd;x D for III1JWUS lind rlltionaitl {orallllctivilin
EXPLORE
fI!)'lllrsillgKi\ i!I )'WI one SIDp for onIlfIf! eIlI!'>ter l'PfIew matenalS a.ncI
llIWurces. Prepare lor SIJWISS witfl addiIiatal 1tCl~-$\y!B practice
(JleSIiom. I~ assgmuns md a.cI;;Ijes. weD 1m. sninatioM
aod videos. and mOle!
DRUGS AT A GLANCE
LEARNING OUTCOMES
INSUUN
AftprrNflingthisclKJpl, rhenudMrshouldbf'ablefO:
ptJIJtfillJ
ORAL H'l'POGLYCEMICS
ptJIJt6aJ
KEY TERMS
cU,,"i: ketOiCidosis (DM )
ptJIJtfJlJ
-,.,~
gkonHgenris ptJIJt619
IIyptIQl)'lemic tffKt piJJt619
lIypI'rovnolar t.,pKf)'temK S1iJlf (HHS) Pl'6a1
IIypofJumktfIKt ptJIJt619
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imllin ptJIJt619
imllinauklg jIIlIJttill!
imllinlftinance ptJIJt68J
isiftsoflillgemillS ptJIJt6l'9
RtoiOds ptJI}tiW
SoIllOfJi"-"mentn
ptJIJt 6a1
causing some public health officials to refer to it as an epidemic.Diabetes can lead to serious acute and chronic complications, including heart disease,cerebrovascula r accident
(eVA), blindness, kidney failure, and amputations. Because
nurses frequently care for patients with diabetes, it is imperative that the di sorder, its treatment, and possible complications are well understood.
Ihey~re Iln~hle
~rriVf'_'.
It
679
porting glucose inside cells: no insulin, no entry. Thus, insulin is said to have a hypoglyl~micffffll, because its presence
causes glucose to Jell\\' the blood and serwn glucose to fall.
The physiologic actions of insulin can be summarized as
follows:
- Promotes the entry of glucose into cells
_ Provides for the storage of glucose, as glycogen
- Inhibits the breakdown of fat and glycogen
_ Increases protein synthesis and inhibits glulonrogrnesis;
the production ofunew" glucose from noncarbohydrate
molecules
The pancreas also secretes glucagon, which has actions
opposite those of insulin. \I/hen levels of blood glucose fall,
glucagon is secreted. Its primary function is to maintain adequate serum levels of glucose between meals. Thus,
glllUlKUJI h,.,; ~ h,p"'gl,mni< droll, baall'" illi pr",,,,,,,,, "all""
blood glucose to rise . .. Figure 44.2 illustrates the relationships among blood glucose, insulin, and glucagon.
Blood glucose levels are usually kept within a normal
range by insulin and glucagon; however, other hormones
and drugs aln affe, t glucose metabolism. Hyperglycemic
hormones include epinephrine, thyroid hormone, growth
hormone, and glucocorticoids. Common drugs that om
raise blood glucose levels include ph,mytoin, NSAIDs, and
diuretics. Drugs with a hypoglycemic effect include alcohol,
lithium, angiotensin-converting enzyme (ACE ) inhibitors,
and beta "adrenergic blockers. It is important that serum glucose be periodically monitored in patients receiving medications that exhibit hypoglycemia or hypoglycemic effects.
m~y
be helpful to visualize insulin as a transporter or "gatekeeper." \'/hen present, insulin swings open the gate, trans-
~ )J
P"ncr....
ins~
ALPHA CELL
seaeting
Glucagon~,
i~~~t~~~~~
"
BETA CELL
--'C-- -
Insoi n-
,,,.,,'
LBng..maM
seaeting
Cell. take
up glucose
,~""'"
in pane""",
~,
Islets of Langelhans
Source: Pearsoo fducat/oo/PH CoIlege.
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'")
(0)
.. FlguTf 44.2 Insulln,glucagon, and blood glucose
680
Unit.
DIABETES MELLITUS
Diabetes meUitus (OM) is a metabolic disease in which
there is deficient insulin secretion or decreased sensitivity of
insulin receptors on target cells. resulting in hyperglycemia.
Worldwide. approximately 135 million people are believed
to have OM; by 2025, this nwnber is expected to have increased to 300 million. The etiology of OM includes a combination of genetic and environmental factors. The recent
increase in the frequency of the disease is probably the result
of trends toward more sedentary and stressful lifestyles, increasing consumption of highly caloric foods with resultant
obesity, and increased longevity.
PHARMFACT5
Diabetes Mellitus
Ofthlo 16 million Allltriuns who hal'edilbms,5 million probab~ a~
unawalt' thu thry hav~ thf dileas~.
E,ch day, mo~ than 2,000 proplea~ diagoosed with diabel!-!.
Gestational diabetn Iff!!. about 4% of all pregnant womm in tilt
United Statn ~a.c:h ~r-about 115,000 m~s.
Diabms CiI!MSalmost 200,000 d~aths~a.c:h ~ar;it is t~ siuh !tading
wuofduth.
Diabms is thf !tIding talM of blindnl'ss in adults;uth )'rar 12,000 10
24,000 ptopIt ~ their sight beCiluW' ofdiabrt~.
Diab~~5 is I!1plMib!t for SO% of nontraumatir Iowt'r~imb ~ mputltions;
56,000 imputations af"! prrformed NIh yw on p~liM1S with diabetn.
Diabetes is the leading CilUW' 01 ~nd-stagt ~nal disuW', mounting for
about 40% of new meso
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diabrlicketoacidosis{DKA), which may progress to coma and possible death if untreated. DKA occurs primarily in patients
with Type 10M.
Insulin
Insulin first became available as a medication in 1922. Prior
to that time, type I diabetics were wtable to adequately
maintain normal blood glucose levels, experienced many
complications, and usually died at a young age. Increased
insulin availability and improvements in insulin products,
personal blood glucose monitoring devices, and the insulin
pump have made it possible for patients to maintain more
exact con trol of their blood glucose levels.
example, the patient participates in heavy exercise. The insulin may have been administered on schedule, and food
eaten, but the active muscles quickly use up all the glucose
in the blood, and the patient becomes hypoglycemic. Patients with diabetes who engage in competitive sports need
to consume food or sports drinks just prior to or during the
activity to maintain their blood sugar at normal levels.
Patients with diabetes who skip or forget their insulin
dose face equally serious consequences. Again, remember
the fundamental principle of insulin pharmacotherapy: The
right amount of insulin must be available to cells when glucose is available in the blood. Without insulin present, glucose from a meal can build up to high levels in the blood,
causing hyperglycemia and possible coma. Proper teaching
and planning by the nurse is essential to successful outcomes and patient compliance with therapy.
Many types of insulin are available, differing in their
source, time of onset and peak effect, and duration of action. Until the 19805, the source of all insulin was beef or
pork pancreas. Almost all insulin today, however, is human
insulin obtained through recombinant DNA technology because it is more effectiw, causes fewer allergies, and has a
lower incidence of resistance. Pharmacologists have modified human insulin to create certain pharmacokinetic advantage5,such as a more rapid onset of action (Hwnal og) or
a more prolonged duration of action (lanius). These modified forms are called inlulinanalogl. The different types of insulin available are listed in Table 44.1.
Doses of insulin arc highly individu"lizcd for the precise
control of blood glucose levels in each patient. Some patients require two or more injections daily for proper dia-
681
"n"
i!IIUin ~ !pirt (Novolog)
""""
.'"
Onset
10020min
""'.
1- 3h
5-15min
.'"
15- lOmin
lD-60min
1-5 h
12h
..
isophi~ 1lI1J11HPH,
kll~RII'diatt
AdmtntsUatlon
andTlmtng
1-5h
.'"
Duration
1-1.5 h
Hh
1h
Hh
SubultantOOl; I, min
Compattbillty
~foream~al
6-10h
6-14 h
16-24h
,...",
."""
'-Oh
102H
SubrutantOOl; 1/day
or2/~
1.1h
Hoptak
SubrutantOOl; 1/day,
iiIIII' tim~ mil day
Mlmilrwith~~
HlJIlJlil H)
i!IIUin deimir llfo1mirj
i!IIUin ~~ lli!ntUl)
"'"
"'"
LibraryPirate
102H
SubrutantOOl; rrix
~19i~
682
'*
LibraryPirate
0I~r4ol
683
ADMINISTRATION ALERTS
En",rr that the p;ltirnt has ",fficifnt food and is oot hypog~mlic brio!"!
administffing ~ular insulin.
Rrgular in",lin is thr only typr ofin",lin that may be!Md for IV injection.
Rotat~ injKtion ~tts. When thr patirnt is hospitaliml, US~ Sit~1 not oormally!Md b)' the p;ltirnt when at homr.
Administer approximatrly 30 minut~s brfo~ mrak w ill\Ulin will be abwrbrd and available when the patirnt begins to ut
P~nalK)'megory8
PHARMACOKINETICS
Onsrt: 30~ min subrutanrous; 15 min IV
Peak: 1-4 h lubcutanrous; lO~ min IV
Halflile:Upto 13 h
Duration:6-HI h subrutanrous;30-60 min IV
ADVERSE EFFECTS
Thr most (ommon adverW' efiro 01 ill\Ulin thrrip)' is hypogly~ia. Ifypoglycrmia may mult lrom taking too mum insulin, not properly timing the insulin injection with food intau, or skipping i mral. Signs of hypoglyc~mia
indud~ tachycardia, (onfusion, sW('ating, and drowsilll'ls.lrrittlion al injKlion
SitH may occur, induding lipohypfflrophy, thr accumulation of lat in the al"!a of
injrction. This rffKt is Irssen~d with rotation olinjection SitH. Wright ~in is a
possiblr ~dr tffra.
Contraindi m ions: Insulin is!Md with uution in pregnane,: !"!1IiI1 impairmrnt
or lailul"!, !tvrr, thyroid disNsr, an d among oldrr adults, childl"!n, or inlann.lnsulin should oot be administmd to patirnts with hypoglycflllia. Patirnts with
h)1lOkalrmia should be monitorrd ul"!lully bKiUW' insulin miy worm this
condition.
INTERACTIONS
Dru;rDrug: Thf (oIowiIg substanus may poiI!ntialf twogIy<fmic !/OO!: aIutIoI,
saiC)li!l'I, MAaI, anabok stl'l"oidI, n:lgUftthidinr. Thf loIowing subltarKll may
anligonile ""~frric: fffKII: conicoruroidl, thyroid 00r1llOOf, and tpiIfpImf.
Sl'l"00I ijlUClISf k>mI may ~ inclMll'd with furwrnidf or thWidt dUMino
s,mptorns"'~r&KtionmaybellY\l:edwith~bIod!l\.
li b1l'1": III\~in may ilKfflR umary Nnlylmandtlic acid {VIM I and inlffil'l"!
wi!h IivI'I" tl'IlIand tht"oo flllctioo tem.k maydKr&MlMI\ IfIIIm pomsium,
calWn,andmagneWn.
Herba VFood: Garlic, bilbMy, and girIIeng may potential! tfMo ",p09ycfrric: fffKII
inlUin.
s.... RtfI'I" III MyMlsJni}Kl (Of IIUlIng /'reII Fool! sp11Ii: 111M ttug.
Oral Hypoglycemi<s
Type 2 DM is usually controlled with oral hypoglycemic
agents, which are prescribed after diet and exercise have
failed to reduce blood glucose to normal levels. As the disease progresses, insulin may become necessary for type 2 diabetics, or it may be required temporarily during times of
stress such as illness or loss.
LibraryPirate
68 4
Assess me nt
LibraryPirate
and
(R ationa l ~s)
Pat i~ nt
a nd Family EduUltion
iJl'I1JU(t the ~titnt to rhKk g/urOit Itvtk JIIOR' ~UtrltIy whtn ill Of
IIndtr ItI!! s.11nts1, tsptCillly I5lOCiattd with <I nortllia, 1IIUIti, Of
lOOIiting. may dKrnst inscAin JII'fdI. No(jy tilt h~.1th ~ pnwidtr- if
llllabit tOUI JIOI"IfIII mull dwing ptriodiof iIInt!.s or .Iltss lor I pouibIt
dwl\9f in insulin dv..t.
"lurn the p.1lifnt 1M bentIi8 ofinr~.J1ed lICtirity but!O be9in Iny JII'W
routintor inauSI' in ~ gradually: ExHist ihoold rut I hour .alt~r
.a mfal Of .aft~r al()" ()J 15-g Cbohydratt IIW<l to prf"mII. hypogl)'(trnii.
IffltMt is probJgfd. .rniI.~1 Qlbohydr.ate Irwrb an ~
rOlllUmfd f'H'1J 30 minute during ~XtrtiSI' It lJIiinllm blood 111gB.
IJlltnKt tht palifm to rhKkglurOl~ Itvtk JIIOR' ~lItrltly, briore Ind
amf~.
(Conrlnued)
LibraryPirate
686
Unlt l
InslnKl tIM> patient on !he III'td 10 rotlte insulin injKtion Y1l5 on a Wffki\'
bali! 10 plt'l'Ml lisWl' damagr or 10 rotate wbc:utaneousrnhtltf sites
(ifllUlin pumps) ~ery2 10 3 days.
Tth !he patient methods for proprr ll000geofinsulin and for s!Oragr
ruring tral'l!!.
TIM> p.atien~ famii\', ort.lrt<jil'f should beablt!O stltr tilt INIOn for lilt
dflllj;oIppropriate~and schtduling;what oIoM~ rllem to oiufft for
and wlltn !O report;nd any Ipt<ial fI'I1uin>mrml of medication tllrrapy
(e.g., ifllUlin nted! during ntf(~ iIInffi J.
InslnKttlM> [)alient to tarry a wallet idl'miflt.ltion card or Wl'ar medical
ide mifiulion jroMlry ind it.Jting diallt1I5.
--+--
by (onfirming thn patient goak and tllpr(ltd ootrome hoM ~n mrt (Iff "Planning1.
LibraryPirate
SULFONYLUREAS
The first oral hypoglycemia available, sulfonylureas are divided into first- and second-generation categories. Although drugs from both generations are equally effective at
lowering blood glucose. the second-generation drugs exhibit fewer drug--drug interactions.
The sulfonylureas act by stimulating the release of insulin
from pancreatic islet cells and by increasing the sensitivityof
insulin receptors on target cells. The most common adverse
effect of sulfonylureas is hypoglycemia. which is usually
TABLE 441
Oral Hypoglycemics
Drug
ALPHA-Gl UCOSlDASE INH IBITORS
Adverse Effects
ik<lrbost (Prt<ost)
mkjitol(~t)
IImlIlb:WIlii!irmllm Ihlll!ilniml~
BIGUANIDe
mtefonnil
XR.GlI.II'IK:UJ
~iridt
(Plilncln)
ytun pancrwiM
IfIIIMq hstbum,diuilli!!.\,
toLmmide (Tolinast)
Iwdht, iJrrJOrwss
loIbtn~ldt{~tl
IfIIlISfO.wrllum,dizzillm,
glipizidt (GlU(mI)
Iwdht, dlflWlirwss
glyburilt (Di.J8tt, )
THIAZOLI DINEDIONES
piogIilalOM {Ioctos]
rosicJlitazorlt (AYiIlCN)
blood
""""'"
Uff'IJ repfflfOly 11fto(tiln, ~9tl.
IIN1ht,tdIJIIII, wright gail
WmtnilgtfCHfdmlt!l li'm
......
mn.JUdt (SyKU)
-'"
"""'"
Ihlllli!ol!kim
(CmtlnUJ)
LibraryPirate
68 8
Unlt l
"n"
Adverse
gipizilk-'!rnf,tlonnin (""'ta~ip)
glytuilrJrnfifonni'l (GilKovanc:~)
"'~
Effects
COMBINATION DRUGS
l,OOOmgmNfomioJ~)
BIGUANIDES
MetfomIin (Glucophage), the only drug in this class. acts by
decreasing the hepatic production of glucose (gl uconeogenesis) and reducing insulin resistance. it does not promote in
sulin release from the pam:reas. Most advern> efTects are
minor and GI related,such as anorexia, nausea, and diarrhea.
Metfonnin does not cause hypoglycemia or weight gain,
which are major advantages of the drug. In addition to low
ering blood glucose levels, it lowers triglyceride and total and
lowdensity lipoprotein (LDL) cholesterol levels, and promotes weight loss. Rarely, metformin has been reported to
cause lactic acidosis in patients with impaired liver function
due to the accumulation of medication in the liver. Sustained
release forms of metformin {Fortamet, Clucophage XR, and
Glwnetza} are a..... ilable that allow for once daily dosing.
ALPHA-GLUCOSIDASE INHIBITORS
The alphaglucosidase inhibitors such as acarbose ( Precose)
act by blocking enzymes in the small intestine that are reo
sponsible for breaking down complex carbohydrates into
monosaccharides. Because carbohydrates must be in the
monosaccharide form to be absorbed, digestion of glucose is
dela~d. Theseagentsare usually well tolerated and have min
imal adverse effects, such as abdominal cramping, diarrhea,
and flatulence. Liver function should be monitored, as a small
incidence of liver impairment has been reported. Although
a1phagh,,;uociJ ...... i"hil>ilun; Ju uul pruJuu< hypugly,-"uua
when U'led alone, hypoglycemia may occur when these agents
are combined with ifl'lulin or a sulfonyiurea.lfhypoglycemia
does develop, it mwt be treated with glucose and not sucrose
(table sugar), because the drug inhibits the absorption of su o
crose. Concurrent use of garlic and ginreng may increase the
hypoglycemic action of alphaglucosidase inhibitors.
LibraryPirate
THIAZOLIDINEDIONES
The thiawlidinediones, or gJitawnes, reduce blood glucose
by decreasing ifl'lulin resistance and inhibiting hepatic gluco
neogenesis. Optimal lowering of blood glucose may tm J to
4 month<; of therapy. The most common adYerse effects are
fluid retention, headache, and weight gain. H ypoglycemia
does not oocurwith drugs in this dass.liverfunction should
be monitored, because thiazolidinediones may be hepato
toxic; in 2()()(), trogJitazone (Rezulin) was withdrawn from the
market because of drugrelated deaths due to hepatic failure.
Because of their tendency to promote fluid retention, thiazo
lidinediones are contraindicated in patients with serioU'l
heart failure or pulmonary edema. In 2007, black box warn
ings for congestive heart failure and for increased risk for my
ocardial ischemia were added to the rosiglitazone label. Using
this drug class in patients with heart failure can increasefluid
retention and exacerbate heart disease.
MEGLITINIDES
The meglitinides are a newer class of oral hypoglycemics
that act by stimulating the release of insulin from pancreatic
islet cells in a malUler similar to that of the sulfonylureas.
Both drugs in this class have short duratiofl'l of action of 2
to 4 hours. Their efficacy is equal to that of the sulfony
lureas,and they are well tolerated. H ypoglycemia is the most
common adverse effect.
NEWER AGENTS
Several new drugs have been approved that act by affecting
the incretin-glucose control me.:hanism. Incretins are hor
mones secreted by the intestine following a meal, when
blood glucose is elevated.lncretinssignal the pancreas to increase ifl'lulin secretion and the liver to stop producing
glucagon. Both of these actions lower blood glucose levels.
Diabdi<.pati,,"l> ar" ullal>l" lu ,,,<.rt:\,, ul<.rdulS iu ~J""lua'"
amounts, thus disrupting an important glucose control
mechanism. Drugs may be used to modify the incretin system in diabetics in two ways: by mimicking the actions of
incretins, or by reducing their destruction.
Exenatide (Byetta) is an injectable drug that mimics the
effe.:ts of incretins. Exenatide lowers blood glucose by in
0I~r4ol
689
,""".
Strum gu.:osr Ieffis shoold lit obtaintd ~try 3 months,i nd tht, clost adit/llod a{cordinqly.
Oiuontillll' lIII'dication imrntdiatr~ if signs of "idosis orr prrsenl
P~nalK)'<.iIegory8
PHARMACOKINETICS
Onset: Its. thdo I h
~k : I- J h (regular rriNlI'); 4~ h (tlttndtd rMm)
Halflift': 17 h
Duration: 12 h (rtgular II'iNst};2( h{nttndtd ""NSt}
LibraryPirate
ADVERSE EFFECTS
Th~ most <om ..... n . <MIW .ffom orr GI ... latod And in<kId. na",~ .. """iting.
abdominal disc:omfon, mmlli< taSit. diarThta, and anorexia. k may .Iso <OUII'
headacht. dizzilll'S~ <lgitation, and fatigut. Unli e the IUlfoo~ull'as. OII'1form in
.. rrly {alMS hypogl}o:t mia or wright ~in. Tht most
ad!,M tffed is
lactic:acidosis,whim is i "II', though plttntiallyfatal,condition.The riskfor lactic: icidosis is ilKrr.1N in patients with renal impainnrnt, liYer dista~,s~~
infrction,('I(nY!' akohol intae, shock,or hypoumi .
Contraindimions: Mrtfonnin is coomindic:atod in patients with impairrd .....
nal function, btciUll' the drug <on list to lOIic Itffls. k is ilso {ont.. indicOltd in
patients with hei n failu .... liYer faikJ .... history of Llctic: "idosis, or {onrurrrnt
miolJ! infK!ion.1t i5 contraindicated for 2days prior to and 2days .fler rrcffl-.
ill9lV r.diographic: (ontrast Metfonnin is ustd with <oution in patients with
antmi., diarThta, rorniting or dthydration, frYer, gastlOparrsis, or GI obstllJ(tion; oldtr adults; hyJll'rthyroidism; pituit.ry iosuffic:ielKr. trauma; ind prrgnancy and Iact.tion.
stnous
INTERACTIONS
Dru;rDrug: AkohoI inmns iMrist forlao:tic: ao:idosis.Captopri~f~,and
niWp~ ma>f ~ tht> r~t for hypc9yr:fmia.1ke with IVraciographil: torlUN
may caust IKtK acidosis ioo aU!\' rtoal failUrt.1lIf folowill9 aug. I!Ia'f dtoMe
renal oUftion of rMformin:.mIoridf,<irnetidof, ~i1,oo~idt,lIlicIoctiIt,
ImljOne,prwinamile,q..rilioe. rani:idioe. triantmne, trilll@l.m,aoo
'I.lOOIOI)'<in.Acarbase OW)' dKrNIt blood IfwIs of IIIfIformin.1ke with olhfr
.JltHiabW< aug. plrtrliites h)1lOljlycfllic. fll"em.
Liil Tl5Is:ioieriorroi1l!1a'f IiIW iakf-poW'/f rtSlits fur IIinMy i21ones.
Herba VFood: MMforrnin declNlfS 1M absorption of litamirl 8" and folic acil. Garlic
.!lid gillfll!j may iooUlf h)l109lyu'II1ic etIim.
lINi ment of Dftrdose: For ~rdost or ~Iopmfnt of lactic: acidosis, hemodialysis <on bt usod to corrK! the acidosis and remo'/t ('I(ffi IIII'tfonnin.
9/!{pf 10 M)Nurllllq/Ql for Q NlJrlifll) I'rIKm fool'; lpKlk 10 rN<i drui}
690
Unlt l
Assessment
--+
Ensure dietal)' nl'tlk are mtl ba>td on the need to Iose,gain, or maintain
cuntllt weight Ind gluro\e Ievell.Conluh with a dietitiln is needed. umit
or tlimioatt akohol Ust.(Adequate ulori{ amounts and protein,
carbohjdralt'S,and fats supponsoral hypogl)'(tmic regimen forgllKolI'
mnuoLActjyity and lifestyle will ilsa ~ fil{\olt'd imo d~tal)' man~9fmenl
Alcohol tiln raill' and then plI'(ipitOlJlIy IoWfr blood sugar as akohol is
IIK'tabolizrd, l<Iising the lis kof hypoglyct mia. Patients on IUlfonyluR'as
should awid or tliminate akoholtntilt'~ to pl"fffnt a disufiram-like
R'adion.)
LibraryPirate
Re>iiew cumnt diM, lifestyle, and adjyity Itvel with the pat~nt.Anill9f a
dietitian {onsuh bill'd on the I'ftd to alter dirt or food choic:es.TNth the
~tirnt to limit or t liminalt'akohol ulI'.lf ilkoholic ~verages are
mmsumed, limit to On!' per day and take i long with i complete mtal to
enlUre that intake balaoces akohol metabolism.
Imtrutt the patient on sulfonyureas (t.g. glyburide) to avoid or t liminalt'
almholull'.
NCLEX-RNOREVIEW QUESTIONS
A type 2 diabetic has been NPO sinU' midnig ht for surgery in the morning. He has been on a combination of
oral hypoglyU'mic agents (OHAs). What would be the
best action for the nurse to take concerning the administration of his medications!
1. Hold all medications as JX'f the NPO order.
2. Give hinl the medications with a sip of water.
3. Give hinl half the original dooe.
-4. Contacllhc health OIl"<" provi<kr for funhcr orders.
LibraryPirate
LEARNING OUTCOMES
(Ortho-NovumJ
,.695
,.XXJ
,.fiJt,
...
EnjuviQ,I'mrnI,;,,/
IIfti\lS
Progeltlm IIIfti'OlJ
...
Q m~t.I .-aaral.",",""Q)
~
Oxytodo ,.u
Q oxyrodn(Pirodn)
fJIIIJ'}QI}
Prostaglandins , . JOI
TIXoIytics fIIIIltJr1l,
DR\JCiS FORFEMAU INFERTIUTY
ANOENOOMETRIOSIS
,.m
KEY TERMS
(OIpIIl luteUIII fJIIJ'695
h_
eIIOtfn fIIJ1'69J
IIIfMIYNO jIIlIJt;t\l
o.,.1I1iMl fII1J' fiIj
JoIid@'itilllWlinlitormOIll![FSII)
jXkT695
gtnHOtropilHtlrning hor_IGnRH )
... m
LibraryPirate
111)1000 JlDIT lW
p rog f~ fII1J' 695
piZ/t695
prosuglMlilil
piq lfJ(J
IO(olyt!( fllJll'lW
ormones from the pit uitary glllnd lind the ovaries pro-
used to treat
conditlon~
ductive system.
PHARMfACT5
LibraryPirate
695
ORAL CONTRACEPTIVES
Oral contraceptives (OC) are drugs used in low doses to
p revtnt pregnancy. Commonly referred to as "the piU; they
pr evtnt fertilization by inhibiting ovulation. Selectl oral
contraceptives art' listed in Table 45.1.
696
Unlt l
Ova rian
cycle
Ova rian
hor mone
cycle
1
1
Me nstrua l
(ute rine)
cycle
I
,,
,
];
",,
Secretory phase
Days:
0
7
Flgure45.' Hormonal changes during the ovarian and uterine cycles
Source Peaf50fl fducarioo/PH College.
~
LibraryPirate
14
"
IlIopltl45 Drug; 10< DI"" ...... ' arod (oodlliom 01 I"" F""",'" Reproductlw SY;lem
Releaw
ot GnRH
C"
""
OvUBlion
Maturation ot follicles
Secn!lioo of &atf098n5
DlMllopfTlllOl cI corpus lutllUTl
Secn!lioo of progestins
reproducllve hormones
A U>IllIllU" l'fUul"Ill will, OG, ""d likt:ly lh" Ill""t [r,,quent reason for treatment failure (pregnancy), is forgetting
to take the medication daily. If one dose is missed, two pills
taken the following day usually provide adequate contraception. If two consecutive doses are missed, two tablets should
be taken on the day the missed doses are remembered and
LibraryPirate
697
700
TheEO>dornn ~ Sym'm
Unlt l
d)'lll1~OOIrht.J .
,"
ADMINISTRATION ALERTS
Tilblru must be uun ~dly U dill'tled
II a dol!' is misstd, tallt as soon as remembeml, or ullt two tabltn th~
III'lttday.
Peak:l mo
Halflifr: 6-45 h
Duration: 3- 27 h
antit~
&
COMMUNITY CONSIDERATIONS
LibraryPirate
INTERACTIONS
I)ug-l)ug: ~n,1OIIII' i~tibioOO,harbituritel,antitorMHam.DI
anlifl.ngik dKIl'u1lll' ~ ofOCs, ilcrN~ng tilt riIk of~ blefdi09
DltMpos~uit,of~.~mllli)'dKIl'N1III'~lofOlill
P.egnalKY megory X
PHARMACOKINETICS (PO)
Olllf"t: 30-60 min (I month 10. (ootra(eption)
ADVERSE EFFECTS
Tht mOlt iIl'~m ila.rrll' ~ffe<ts of Onho-Novum a.f naUll'iI, brem tfnde.IH'IS, Might gain, and bll'ilkthoough bletding.lrss (ammon ~(I\ indude
edema, (hanges in ision, gillbbdde. dill'.m, nausu, ilbdominal (rimps,
(hanges in urinar; function, dysmenorrhra, brmt fulllll'lS, falicjut, skin rash,
imr, hNdoKh~, "lilginal undidiasis, photOll'nsitivity, ind (hanges in urinar;
pinrms. Cudic:wll(ula. adl'rrll' tifeell, the mol1l1'rious of all, indude hypt.tt nsion and thlOmbotmbolK dison* ~
Contraindi(a\ions: 0Cs all' (ontraindicated in wolIII'n with the Iollowing (00ditions: QJlTI'm o. past history 01 thrombotmboll disordel5, strou, 01 roronar;
anl'rydill'~ lI';hepatic: tumors; known OIsuspt<lfd un:ioolllil of the brNst,endomtlrium, 01 oth~r ~strogtn~ndem tumOl; ilbnormal ulI'rilH' bletding;
dIoIfSIatic jaundlt of Pll'9ni IKY 0r jaundn with prior oral rontr.Krptil'l' UII';
known OIlUIpt(ted pfl'9l\ancy.
Lab Tem: ViUes of 1111' following Ina')' bt inc:1NSed: jnIInwnbin iiIIII', tfrtlin
<Ngwtion Iactoo, thyroidbindiog~in,P8I, T.. plalrlel ~tion,ind
Jr9ytfridel. YiIkIfs of tht IoIowing may bIo dfo"NSfd:antitl"lOlnun III, T" foIilf,
Dllitamin 8".
EMERGENCY CONTRACEPTION
AND PHARMACOLOGIC ABORTION
Emergency contraception is the prevention of pregnancy
following unprotected intercourse. Pharmacologic abortion
is the removal of an embryo by the use of drugs after implantation has occurred. Drugs used for these purposes are
listed in Table 45.3.
UTERINE BLEEDING)
Assessment
Implementation
Interve nti ons and (Rationale s)
Ensuring thtrilptutic rffects:
Monitor iPPropriall' m~diatOO administration for optimum 1!"SlJ1ts.10Cs
all' lI!'arly 1m effffiiYl' whrn ta~n ilS lI'quill'd Skipping dam ilKr~'1e
the risk of PlI'9nilllty. Mainta iniog (olllilltllt daily dole! for lII'atmern of
m~nopaual symplOtm or dysfunniollill ut~rint ble!ding will ensull'
hOl",oo.In.1> r. nldin ,ldbir .nd ',"'plo"" "SI'J
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702
UnII l
wok<J
o Ttach the woman with diabectS to monitor Cilpillary blood wgar f1Im
frtqUenliy while on drugs contai niog tsttogefl iI ndIor progtstin iI nd rtpOrt
consistent tlt'lations to tht huhh Uft pro"Iidtr.
o Tfach tIM: patient to alMst all heahh calt providtrs of the ust ofalrogens
aodlor progtstin I for contf<Ktption orfor hormont replactffltrlt therapy
bfiofl' btginniog 'fly IH'W prtSCription.If' pmcriptiorr is Ifqui"d, discUls
the nrfd for ah('fllati~t utatme:nt or birth control mtISU"S as oI ppropriollt.
o Monitor yt.lrly Pap ItsIS ,nd In,st eums.(AnOUolI Pap tests and b"alt
t:urm, inckidiog mol mIMgraphy 's appropnatt, will monitor for the
dMloprnrnt of brtast tumors or of cfrvic:al (anerr or HPV infection.)
o Ttol(h the patitnt that ~ight sporliog mily occur midcydt while on
hormolH' drugs but to rtpOn any uOlIIU,1 chiflCjfl in tilt ilmount or if
blttdiog continUts.
LibraryPirate
o Thr patient should lit ,ble to state thr Jtol lOn for thr drug,appropriatr
dolt ,nd 5Chrruliog,and what ildIotBl' tffts to obitlVI' for and when to
rtpOn thrm.
IlIoplfl45
Drug; 10< DI"" ...... ' arod C""dlliom 01 I"" F""",'" Reproductlw SY;lem
703
Evaluatt tht rf~tienl'ls of drug thtrilPY by ronfinning that p;ltitm gNlsand 6 pKted oUl<omrs hal'l' been met (="Planninif).
TABLE 45.3
Plan B must be administered as soon as possible after lUIprotected intercourse; if taken more than 72 hours later, it
becomes less effective. By 7 days after intercourse, it is ineffective at preventing pregnancy. The normal rate of pregnancy from a single unprotected se."t act is 8%; Plan B is
estimated to lower this risk to 1% to 2%.Adverse effects are
mild and may include nausea, vomiting, abdominal pain,
"n"
EMERGENCY CONTRACEPTION
1e~(PlanB)
PHARMACOLOGIC ABORTION
urbopoll trommamin~
(IItmabatr)
miftpristOlll'(Miftpll'l)with
misoprostol
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='
70 4
Unlt l lheErdoulnrSym'm
MENOPAUSE
Menopause is characterized by a progressive decrease in estro gen secretion by the ovaries, resulting in the permanent cessation of menses. Menopause is neither a disease nor a
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a..p1fl4S
Prototype Drug
Therap~ti c Class:
705
Hormone
PHARMACOKINETICS (PO )
On~ : Unknown
ADVERSE EFFECTS
~~ effects of conjugattd estlO9f1n ilKludt n~USI'a, Huid Il'temion,
t<itma, bll'ast tendernrss, abdominal era mps and bloating.. anne palKreatiti ~
apptlitt cliaogrs, acnf, mental dtpl!1sion, dtclNW'd libido. headache, fatigut, nt IWusness, and wtighl gain. HfKts art dos~ dtpeodtnl. [!IIogen~
when ustd alolH', haW' br~n associated with a hightr risk 131 ultrilH' canm. A~
though addinga progestin may txert a protlivt tfl"rct b)' IooMring the risk of
uttrinf cancr~ salll!' studirs suggest the progtltin may ilKll'awo the risk of
brt'ast cancer fallowing long-term USI'. The risk of adVl'Bt eflem incll'alt in
patitnu O'II.'r age lS.
Cantraindi (atians: Conju9olltd r!l'OCjtns all' cantraindicated in prtgnant patients and in women with known or IUIptlted carciooma of the bll'ast or other
rstroqeo-dtpl'ndent tumor. Caution should be ulI'd when tll'ating patients
with a history of thrombotmbolic diINwo, hepatic: impiillOl'nl, ar aboormal
uterine blttding.
INTERACTIONS
Drug-Drug:Orug interaction! i1d~ a ~ .ffKlolt.lmOmfO, enharKed
cortKOIIl'loid Iffl'ttS, 0100 dKrNIfd . frem of an\i(oagU.n~ l'IpKiaIy wirlaril.
The !ilKI'! of l'Wogeo IOi)' bt dl<lUed ~ takfll with bartitwles or rifamjin, and
thffi' is a pos~twin(JNll'deflKt of tricyd"K Intidrprl!lsam I t.lbowith ~
Herba VFood: Red dovn and blad cooOlh IOi)' n!Hffno w~h HtrogIO tll5.,.
EIIlns of l!llrogtn IOi)' bt ert.anced if cOll"lJinfd with ginlfllg.
P9k: Unknown
Halflife:4-13h
Duratian: Unknown
~ distUrb.Jncrs,dtpIl'sWl,irritabiity
....
" lOmnia
"'
Hfidicbtl
Vaginal au~~ incrtill'd nftnion~ p.linful
inttl"lJlI.rII'
Skin atKljtly
SexUoJI dsintemt
Cirdio....uculilrdiltall'
..""""
Allhtimtr'riR dtmtntia
Colon cancer
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UTERINE ABNORMALITIES
Dysfunctianal uterin~ bleedin g is a condition in which hemorrhage occurs on a noncydic basis or in abnomlal amolUlts .
It is the health problem m ost frequently reported by women
and a common reason for hysterectomy. Progestins are the
drugs of choice for treating uterine abnormalities.
706
Unlt l
45.6 Pharmacotherapy
with Progestins
Secreted by the corpus luteum, endogenous progesterone
prepares the uterus for implantation of tht' embryo and pregnancy.lf implantation does not occur, le~ls of progeslt'rone
fall dramatically and menses begins. If pregnancy occurs, the
ovarycontinnes to secrete progesterone to maintain a healthy
endometrium until the placenta develops sufficiently to begin
pr<XIucing the hormone. Whereas the function of estrogen is
to canse proliferation of the endometrium, progesterone limits and stabilizes endometrial growth.
DysflUlctional uterine bleeding em have a number of
causes, including early abortion, pelvic neoplasms, thyroid
disorders, pregnancy, and infection. Types of dysfunctional
uterine hleeding include the following;
Amenorrhea- absence of menstruation
Endometriosis--abnormallocation of endometrial tissues
Oligomenorrhea- infrequent menstruation
Menorrhagia- prolonged or excessive menstruation
Breakthrongh bleeding--hemorrhage between
menstrual periods
Premenstrual syndrome (PMS )- symptoms de'A'lop
during the lu teal phase
Postmenopausal bleeding-hemorrhage following
menopause
Dysfunctional uterine bleeding is often caused by a hormonal inlbalance betw,n estrogen and progesterone. Although estrogen increases the thickness of the endometriwn,
bleeding occurs sporadic.ally unless balanced by an adequate
amolUlt of progesterone. Administration of a progestin in a
pattern starting 5 days after the onset of menses and continuing forthe next 20 days can sometimes reestablish a normal,
monthly cyclic pattern. Onll contraceptives may also be prescribed for this disorder.
L IFESPAN C ONSIDERATIONS
ADVERSE EFFECTS
MrdI"tlq'PIOQI'II~1OIIl' is .J
The most frrlJlrm ,dvr~ rffrm of medrol:)'Plogrsttronr alt' brtm troderIII'SS, lmoakthrough blrtding. and other menllru,1 irrfgularitits. Wright gain,
dtpJl'Soon, hyptnt noon, n'lIIN. yomiting. dysmt norrlle.J, and 'I<lIginal LIndidialis may , Iso oc:rur.1hr moll serious ,dvern rffffi is , n ilKlNseri risk for
thrombotm bol ic: dismf. The drug has a blld box warning that !lSI' of tht drug
may Ll!lSl' a Ion of bont mineral derJ~1)'.
Contraind ications: Medrol)'plGgesttronr is (onm indicated during prtgnanC)'
.J nd in womtrI with known or suspled (artinoma of the brtul (.JUlion Ylould
lit used when IImill9 patirnu wilh a history of Ihrombotmbolic dill'~ hrp,tic im])ailllll'n~ or undiagllOled vaginal bftding. Tht drug shoold br usrd
Lltnious~ in patienu with a histoll of psychic: drpll'Soon and thr drug discontinued at t~ fillt sign of IKUrrill9 dtpr~oon.
synthetic plOQI'Itin with a proJolIQrd duration of oKtion.As with its natural (oumt rpart, the prim,ry t'''ltllissur lor mtdrol)'progrstrrolll' is the t ndometrium of ~ U1l'M. k inhibits t~tffr(\of estrogen on
the U1tru~ thus restoring oormal hormonal balinft'. Applications indudt dysfunctional U1t rine bIte:Iing. Sf(ondary amtnorrhu, and (ontroKrption.
Mrdl"tlq'progestflOlll'mayalso brg~n 1M forthr ])allialian of mmstatic:tnerint or It'nal Glruooma and <II a susuined rtlt, 1I' form (Otpl-Pl"ll'Ur.J) for
(omrac:fption.
ADMINISTRATION ALERTS
Prtgnanq rntgOry X
PHARMACOKINETICS (PO)
il1S!'t Unlmo'Ml
Peak:2-.4 h
Half~ife: 30 da~
Ouration:Unknown
INTERACTIONS
])ug- ])ug:Strum I@ve/sof meriroxyprogl'lletOOf ~", deomPd by
amiooglutflhinidt, barbinratH, jHnilonf, rifampin. rifabutin, and topiramatf.
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a..p1fl4S
In cases of heavy bleeding, high doses of conjugated estrogens may be administered for 3 weeks prior to adding
medroxyprogesterone for the last 10 days of therapy.
Treatment with nonsteroidal anti-inflammatory drugs
(NSAIDs) sometimes helps to reduce bleeding and ease
painful menstrual flow. In 2009, the FDA approved tranexami<: acid (Lysteda) for the treatment of cyclic heavy menstrual bleeding. If aggressive hormonal therapy fails to
stop the heavy bleeding, dilation and curettage (D & C)
may be necessary.
Progestins are occasionally prescribed for the treatment
of metastatic endometrial carcinoma. In these c~, they
PO;05-2mgdaily
Tranldmnal ~tdl; I ~Kh titlltr onc:~ wmJy (Oimari) ortwia 'IoftkIy
(0.025-0.1 mgltlayj
Intril'ilginal ~am; nstrt 2---4 glda, for 1 wk.tllffi Iflb:r to Y:.tll! iI~ial dose
for lwk, thtn UII' I 9 _ to th~ tinel/wffl;
(ypionatt
gallbladde(
HyQffi~Dljoo
djIwr tbmmbPflnbg!j(
~lIIIdio!
707
(Ctntltin, fnjll'lii,
1M;lo-1Omg~1'tf1 4 wk
Prrmarin)
l'S~te(Ckjen)
PROGESTINS
Q ~trOIIt(~Prv.'i,
~f'Ivffl"i,f'Ivffl"l,(,mn)
PO;~IOmgdiilyonday; 1 - 12ofm~nstrllollqdt
1M iIltpo--PKl'lffil); ISO mg daily 10, 1 months.Givt til! fi~ dose dJlilg ttw, firs!
Sdays ritht lllfflSlrual period or withil til! fi~ Sdays postpanum if not
brffil-fffililg
S!.tKuta!leOlll (depMlbQ-Prom"lit 104 mg !!aMy for 3months. GiYe the first dose
dlling til! rrll 5days of til! menllnJill pffiod or at ttw, 6th WffI; postpanum if not
brulIfffililg
iwMllffllitml'lJ, wtighrgDin
AmmorrIIN dl'll!ltllOl!!ltt,
*,,'6~on
Ihrombornlbolic:
""""
ProdtiM, Promtlrium)
1(J().mg ubltis
mrdrOX)'procjI'neron~ (Prrmpha~,
-",)
(Aail'elli)
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70 8
Unlt l
Adverw Effects
OXYTOCICS
Q
oxytlKi11Pitodn)
ERGOT ALKALOIDS
trgOIIOI'il~
maleall' (Ergotrale)
meth)"lft9OOO'lint maiNte
(Methm;int)
Iiwlfo.lOmiring,umint CTaI1I'1'f1g
PROSTAGLANDINS
~st(HffilaM:~)
Promn E,)
misoprostoilCytottt)
TOCDLYTICS
magntsi:Jm !Ufat~
IV; 1-4 9 ill 5% r1e1lrOlt byskM infusion ~riliil max dolt = 10-14
gld.y. tiH-'o 110 mOl! tlwllo-40glrlay at oJ max ratt of 1 ~1g"')
I'O:lniliai dosage of 10 mq. foIowtd II)' 20 mg orally all~30 min
HcontrKtions pmill, tiH-'raP'f un be cortiooedw~h 20 rng Dlaly
Mf'/ l~ 8 h for 48 ~n hw~h a maxinum doItof 160 mglday
Aller 71 hoIn, if maifteDilK is u~lll'quirro.lonoJ-Kting
nifedipillt 30-60 mg daily un be used
1V;1.5~ 10 II\(glmill; irKru~ MI1102fj minUles;dll"Jtion of
iofusioo = 12 h lmax: 17.5-30 II\(glmin)
I'O:mailttnallll'riosI':1.5 IOmgMf'/4-6h
Ruslirrg,fMQring,musdt wfaknru
Coml!!~t~
""'""
=" ".. ,
Ruslirrg,lliI'Qring,musdt W!atnru
I
, ;,
IiffI'lJlJlMJ,lrPmot;~J
[tioIlb!:oII1Wf
Irdb iodiute (OO1mon oJdvmt di'ttlS; !llderliri!l!! indiute serious adm~ di'ttls.
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IlIoplfl45 Drug; 10< DI""..... ' arid (""dlilom 01 I"" FE'ma'" Repmductlw 'ytlem
Hypothalamus
sends impulse to
~~u,~
po!lt""'" p'tu~ary
"-
~,
Muscles contract,
"""'~~
Milkproducing coil.
Flgure45.4 Oxytocin and breaslfeedlng
~ Prototype Drug
u[ l'ul~"li<oJ
,huul<.l ""."r],"....,<.l
/thalam.m
Milk
709
I Ocytocln (Pltocrn)
PlI'9nancy uttgory X
PHARMACOKINETKS
Onset: Immf<lialt
~k: Unknown
Halflife:1- 5min
Duration: 1h
ADVERSE EFFECTS
The m05l (ommon adl'l'~ efftcU d oxy\O(in aft' rapid, painfUl uttrill!' rontrac:lion, and fetal 1a(/)ytardia.When gi'o'!'n IV; vital signs of the fetus and mother J ft'
monitortd (ontinUOUlly to avoid {omplic:alions in tflt fetus. IlKh a>dysrhythmia I
or intriKl1lnial IN>monhage. Striou> romplic:ation, in the motlN>r may indUiX
utt rine ruplurt', ~izlll'l,OI roma .Ri,k of uteriII!' ruptuft' ill(lN!I'1 in womtII who
ha-;~ delil'!'rt'd fl'l~ 01 mOrt' midrtn. Though nperirnu has mwn tIN> u~ of
ol)'loc:in to lit quitt ,aft,labor Ihould lit induc:f<I by tfI~ drug only whm theft'
art' demonltritf<l ri>ks to the molher orfetus in (Ominuing the PII'9IWIIC)I.
Conllaindi u tions: Antepartum us~ is (ontraindiulf<l in the following: signifKant (fpllaloptlvK disproponion; unfavorable fetal position, that are und~ljy..
erable withoot (olMrWn btfoft' delrmy;oblletric:al ~lI(its in whic:h t~
btnefit-to-rilk ratio for the felUl 01 moth~, fawB IU"lKal ime~mion; fetal
distlffi when delivrl)' is not immint nt;whtn idequat~ uterin~ actjyityfaiis to
oKhieYl> satisfactory PI09rt'ls;whfn th~ uterus is alrt'idy hyperactil'!' or h)opertonK; v.t.en vagilWl dtl~ry is (om,aindic:ate<i, >lJ(h as in~jyt cerYic:a1UK~
noma, aniVI' gtnital ~Ipfl, total placmta prt'Yia, '/.H.l prffia, and (ord
prt"!I'f1tation 01 prola~ of the (Old.
h_
INTERACTIONS
Druq-DIIJ!I: Yol\IXOIISlIinor U!I'd (OII(UflflliIy witl1 oxytocin may (iU!I' W'Il'II'
lJbTesll:UnkrocJrwn
Herba VFood: HI1M' known
TlNt mem of O'ffrdo,e: (Mo,dos~ (aUStlllrong uterine (Omractiolll, whic:h
may lead to uteriII!' lac:eruions orruptuft'.lmmtdiat~ discontinuation of the
dlUlJ is nMSlary,along with ,ymptomatK trt'atment.
Rtftr Ie M)NUrllllgm kif Q IWrli"9 I'rIKJlj fOOI5lpt{1k Ie rIIt! ~
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710
Assessment
---+---------------------
bl-rss~nt throughout
.d.,inlstfillion:
AsIHS iJrdtsftd tlttrapeulir tffn *pmrlt!tt 00 1M IUSOfl wdnJg is
g;..rn (t.g. stlOfl9, ~guI.Il conI/actions supportr.t of..,).
Continuously monitor timi ng. qllillity, and Ibllion of {ontr.lctions.
kII rnediatrly ~port SllStiintd IIIt rine {ootractions to 1M hHhh (,J ~
.......
'lhtpatitlttwi:
Ex;ttrifIKt thtJaptUtic: tffts (f.g., llrong Libor {ontmtiom wpponiv! of libor,~t milk IHdown sUPlXl~of bfNIt-~ poslplfMII blttdill9 is
diminillttdj.
8t frre from,or~Cl.' minillloli. idwnf tffrru.
Ikrbalizt, iIII Ulldmtancing ofw drug's 1M, ~ tfIem,ind requftd prfUUtioM.
Dtmonltri~ proptr !tIf-administration ohllt mtdio:.Jtion (t.g.,d<M, timing. when to notify plll'Vidfr).
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OIIpler 4.
.'"
Tmh the patient that the Ittil heart ratf will also bt monitored along
with UltrilM' contl'ilctions. b:plain the purpose for all monitoring
equipment to allay anlitty.
The p,tirnt should ~able 10 state tIM- rNson for the drug,lppropria~
dolfand ICheduling, monitoring n<ls, and wh.t . mJ'lffim:u to
ob!erY!' for and when to ~pon them.
therapy by confirming that p.nirnt goakand tJ:pfCloo outcomes h,Y!' bten mtI (see Planning").
~ TIIbIe5 45.1 &45.6 for Q lisr ofttugs /01+1ridr fhrst OOM9 lions 1JIfiy.
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711
712
Unlt l
FEMALE INFERTILITY
"
t
45.8 Pharmacotherapy
of Female Fertility
The three primary causes of female infertility are pelvic infections, physical obstruction of the uterine tubes, and lack
of ovulation. Extensive testing is often necessary to determine the exact cause and it is not Wlcommon to find multiple etiologies for the infertility. For women whose infertility
has been determined to have an endocrine etiology, pharmacotherapy may be of value. Endocrine disruption of reproductive function can occur al the level of the
hyrolh~l~mlH. rintit~ry. or ov~ry. ~n(] phHm~rolher~]'>y i.~
targeted to the specific cause of the dysfunction.
Ovulation (and thus pregnancy) cannot occur unless the
ovarian follicles receive a hormonal signal to mature each
month. This signal is normally supplied by LH and FSH
during the first few weeks of the meru;trual cycle. Lack of
regular ovulation isa cause of infertility that can be successfully treated with drug therapy. Clomiphene (Clomid,
Milophene, Serophene) is a preferred drug for female infer-
TABLE 45.7
Drug
br~illl'lP,l1lodd)
I P~tion
nafirtlin (S)nar~)
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o..pur45
monal stimuli, this abnormal tissue can cause pain,dysfunctional bleeding, and dysmenorrhea.
Leuprolide ( Lupron) and nafarelin (Synarel) are GnRH
agonists that produce an initial release of LH and FSH , followed bysuppression due to the negative feedback effect on
the pituitary. Many women experience relief from the
symptoms of endometriosis after 3 to 6 months of therapy.
7 13
45.1 Female t"E'productive function is controlled by the secretion of GnRH from the hypothalamus. and FSH and LH
from the pituitary.
45l Estrogens are se;;reted by ovarian follicles and are respon sible for maturation of the sex organs and the secondary
sex charactE'ristics of thE' female. Progestins are se;;reted
by thE' corpus luteum and prepare the endomE1riWll for
implantation.
45.3 Low doses of estrogens and progestlns prewnt conceptton
by blocking ovulation. Longterm formulations are available that offer greater convenience.
45A Drugs foremE'rgencycontraception may be administered
within 72 hours after Wlprotected sex to prevent implan tation of the fertilized egg. Other agents may be given to
ThE' nurSE' includes which of the following discharge in structions to the p.1tient receiving HRTI
t. Ao,utd foods that contain caffeine.
2. TakE' medication 30 minutes before mm.
3, Disoontinue medication if utt'rine bleeding begins.
4. Monitor for a suddE'n increase in IDLcholesterol
The nurse's assessment of the patient receiving an IV infusion of oxytocin notes that uterine contractions are 4
minutes apart and 60 se;;onds in duration. Which of thE'
following nursing interwntions is most important based
on this assessment?
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1.
2.
3.
4.
_red
714
Unlt l
lhI'Er.doo1""S)lmm
The patient questi ons the nurses a bout how she could
ha ve become pregnant while she was takin g oral contra ceptives. Which of the rollowingstatements best describes
the primary reason a patient wou ld become pregnam
wh Ue on oral co ntraceptlvt'$!
I . Antlblotlcs were taken In conjunction with theoral
oontraceptive .
2. 1\<,0 or more doses of the oral oontraceptive Wl:'re
skipped.
J. The dosageofthe esUogen In the o ral contraceptive was
too iow.
4. The oral oontracepthe was taken I.n combinatioo with
an anticonvulsant.
EXPLORE
~.- - - - - - ,
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LEARNING OUTCOMES
fIIlIJ'lf9
""no
AlpharAdrenerglcBlorurs
pagtm
,.127
KEYTERMS
anibolin teroids fDIF 717
androgl'l"5 fllXJ'716
u oospermiil fX1IJ' 718
libido ptJITlIl
oligospermia fIIXJ' 711
impoten~ fllXJ'719
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716
Unlt l
r~ulated
Ret ....se
ot GnRH
h,pogonadism.
BPH affects 5O%of mtn 0100 than 60 )'NfI,and 9O'Mi ofmen oIdtr than 80.
BPH is tilt moll wmmon btnign ntoplillm alfliog middlHged and
-~.
ApproQmu~
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""
Secmt"'" cI \estostl!,..".,.,
Stimulation 01 spermatogenesis
hormones
ANDROGENS
Androgens include testosterone and related hormones that
support male reproductive function. Other important a ndro gens include androstenedione and dehydroepiandrosterone
( DHFA). Therapeutically androgens are used to treat hypogonadism and certain cancers. These agents are in Table 46.1.
46.2 Pharmacotherapy
with Androgens
Lack of sufficient testosterone secretion by the testes can result in male hypogonadi'lm. Hypogonadism may be congenital
or acquired later in life. \\/hen the condition is caused by a
testicular disorder, it is called primary hypogonadism. Examples of disease states that may cause primary testicular
(hopltl46
Drug. IOf 0110,<1<>" and Coooltian. 01' the Mak> Rep'oductlve 5y;tem
7 17
Adverse Etfl!.cts
dalluol (Danoo:ril~)
PO;200-400mgbidfor 3~mo
meth)"ltffio'teroo~
-""'-
oxandrolorit (Oundrin)
PO; 15-20 mgltlay djyjdtd two to 1011" lim~day for 2-4 wks
oxymrtholonf (Androl-SO)
Bu:c.JI; 30 mg ~ 12 h
IffiomfOM (Striant)
1 daily;Androdffin
(AnItoGtI. Tffiill)
Dtpo--TeltOltmmt)
It'ltOItmmt ~anlhal~
OtIatetryl)
LibraryPirate
profound anabolic effect on skeletal muscle, which is the rationale for giving this drug to debilitated patients who have
muscle-wasting disease.
Auboli ( steroids are testosterone-like compoWlds with
hormonal activity that are taken inappropriately by athletes who hope to build muscle mass and strength, thereby
obtaining a competitive edge. Use of steroids is high
among teens, who sometimes take these drugs because
they believe it improves their appearance. When taken in
large doses for prolonged periods, anabolic steroids can
produce significant adverse effects, some of which may
persist for months after discontinuing the drugs. These
agents tend to raise cholesterol levels and may cause low
sperm counts and impotence in men. In female athletes,
menstrual irregularities are likely, with an obvious increase
in masculine appearance. Oral androgens are hepatotoxic,
and permanent liver d1mage may result with prolonged
use. Behavioral changes include aggression and psychologic dependence. The use of anabolic steroids to improve
athletic performance is illegal and strongly discouraged by
health care providers and athletic associations. Most androgens are classified as Schedule III drugs because of their
abuse potential.
High doses of androgens are occasionally used as a palliative measure to treat certain types of breast cancer, in
combination with other antineoplastics. At the high doses
required for breast cancer treatment, some virilization will
occur in most patients. Because the growth of most
prostate carcinomas is testosterone dependent, androgens
should not be prescribed for older men Wlless the possibility of prostate cancer has been ruled out. Patients with
prostate carcinoma are sometimes given a GnRH agonist
such as leuprolide (Lupron) to reduce circulating testosterone levels.
718
Unlt l
TheEO>dornn ~ Sym'm
"'""
Implantabll-' ptlru
(5lbrutantOUS)
Drug
Advanlages
DI!iadvantages
thfOOsr~Rd.
Intramu5(IJlilr(lM)
",.
TtllOltffiHll' buc:<al
Tramdmnal
tffi05lmr gd
Transdrrrnal
tffi01lmr p.llm
ilytO~
""".,
L IF ESPAN C ONSIDERATIONS
"t
MALE INFERTILITY
It is estimated that 30% to 40% of infertility among couples
is caused by difficulties with the male reproductiw system.
Male infertility may havea psychologic etiology, which must
be ruled out before pharmacotherapy is considered.
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46.3 Pharmacotherapy
of Male Infertility
Like female infertility, male infertility may have a nwnber
of complex causes. The most obvious etiology is lack of
sufficiem sperm production. Ol igolp~ rmia. the presence of
less than 20 million sperm/mL of ejaculate, is considered
abnormal and can lowt'r reproductive success. Azoosp~rmiil,
the complete absence of sperm in an ejaculate, may indicatt' an obstruction of the vas deferens or ejaculatory duct
that can be corrected surgically. Infections such as mwnps,
chronic tuberculosis, and sexually transmitted diseases can
contribute to infertility. The possibility of erectile dysfunction must be considered and treated, as discussed in Section 46.4. Infertility may occur with or without signs of
hypogonadism.
Tht' goal of endocrint' pharmacotherapy of male infertility is to increase spt'rm production. Therapy often begins
with 1M injections of human chorionic gonadotropin
(hCG), three times per week over I year. Although hCG is
secreted by the placenta, its effects in men are identical to
those of LH: increased testosterone secretion and spermatogenesis. Speml counts are conducted periodically to assess
therapeutic progress. If h.CG is unsuccessful, therapy with
menotropins (Pergonal ) may be attempted. Menotropin
consists of a mixmre of purified FSH and LH. For infertile
patients exhibiting signs of hypogonadism, testosterone
therapy also may be indicated.
Other pharmacologic approaches to treating male infertility have bet'n attempted. Antiestrogem such as tamoxifen
(Nolvadex) and clomiphene (C lomid ) have been used to
block the negative feedb:lck of estrogen (from the adrenal
...
Prototype Drug
7 19
I Testosterone
PHARMACOKINETICS
Onl('\: Unkna.vn
Ptak:Unkna.vn
Halflife: Unkna.vn
Duration: 1- 3d.J~ (2-4 Wffks for 1M and ptlltt forms)
ERECTIlE DYSFUNCTION
Erectile dysfunction, or impotence, is a common disorder in
men. The defining characteristic of this condition is the
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ADVERSE EFFECTS
An obY<M, dl'l'Mei'fe(tol Il5ta>ttroll!' therap)' is virilization. whKh is uwal~
only of (olKtm wlltn tht drug is taken by moal!< patitnu.llKfNstd libiCo rna)'
Q(QJr. Salt.nd W"l'f are oiten retJintd, causing tdem and a dUlt'tK may ~
irod icared. Liver da"",* is fare, akhough it is a potentially ~rious ioMf\e tffHt
with 1OIII!'01 tlltorally administtlt'd androgens.Aclll'and skin irritation i;common during therapy. ~male may experience supPfffiion of owlation or mtnstruation. [xtreml' do~ in men (.naboiK I1troid abu~) rna)' talM
kmin~ation ratlltr than virilization bt<iIM ums ~tOlterolll' is ml'ta~oIire:l
to estrogen.
Contraindications: T~tOltffOlll' is (omriindicated in men with kna.vn Of WIpK\ed blNlt or prostatic can:ioomas ind in women who all.' or may bMome
prf9~t (talrgory X).lhe drug shoold ~ uled with uulion in patients with
pre-fX~tinq Il'nal or htpatK disNse.
INTERACTIONS
Drug-Orug: 1rsto1terone may poIefltialr 1M rtfeas of orill alticoagWnll atld
incrHl( tfMo rilIt of s.MIf bIHdiIg. (onrunnt 1IIf d tfllOSItrOM with
cortiul\U'roO! ma, Gl1lIf additi'lf edana. which (iJf1 tit ~ seriom IlIIOO1 [01 thcsf
willt helrt [ai~r~. f\@patOlOlicdrugsslKUdtltiMliderlbtutM!II!'wi:h
te'iIOIIeJOMun tilUlfaddm'lfli\ti~.
La b1i511: YalUfS of 1M foIowin9 may tit deu!Nd:14. th)'rOIilf-binding gIobt.lin,
Iff1J!l a kim, DI donilg 00011 It Y
.I-lI.,nd X. (RIllinnr. may tit inc!Mfd, ltd
cholfsttrol maybf l'ithf! ilaNSN or ~
Herbi IiFood: The rillt of hepal:OIolidty may inoNst whert teI1051eron!' ~ UIfd lrillt
rdlifla(1.l.
46.4 Pharmacotherapy
of Erectile Dysfunction
The incidence of erectile dysfunction increases with 1ge, although it may occur in a adult male of any age. Certain diseases, most notably atherosclerosis, diabetes, kidney disease,
stroke, and hypertension, are associated with a higher incidence of the condition. Smoking increases the risk of erectile
dysfunction by 30% to 60%, in a dose-dependt'nt manner.
Psychogenic causes may include depression, fatigue, guilt, or
fear of sexual failure. A nwnber of common drugs cause impotence as an adverse effect, including thiazide diuretics,
phenothiazines, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), beta- and alphaadrenergic blockers, and angiotensin oonverting enzyme
(ACE) inhibitors. Low testosterone secretion can cause an
inability to develop an erection, due to a loss of libido.
Penile erection has both neuromuscular and vascular
components. Autonomic nerves dilate arterioles leading to
the major erectile tissues of the penis, called the (orpora (aver
nasa. The corpora have vascular spaces that flll with blood to
cause rigidity. In addition. constriction of veins draining
720
Assessment
dIl"",. ..
As~ fur
n.,l" rrdU","", Y"nrnir'I,L h....!""' ~hl 'l"irr.lluid
ft'~ntion.rdrma, ioomed blood pl!"IWJe,changel in mood, irritabilit"and
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(hoplfl4/; Drug' (Of Dllorde" and Coooillon, 01 the Mali> Rep,odunlw S)'5lem
721
Tt.t{h the pillitm. f.Jmily, or mrgimto lIII'illU~ htight OrKe ptr month or
at dir~tM. Return for dinical at!emll'nts at I"ftdtd approximately M'f)'
6 momh, to monitor bo~growth.
Tta{h tht idolescent patient to m.J imain riaily do~ng at instructed and
not to incft'ast dos.igt unltu in ,lnKted 10 do so by t~ htalth Cilft'
providtr.T~ drug shoold never besharrd with others.
The piltiem should beable to !late the INson for the drug. .J ppropriate
dose and S(htduliog. i nd what ad!'rll' rffects 10 obll'r!' for arod w~n to
~por1thtrn.
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722
Unlt l
Thi'Er.doa1neSym'm
~1dma~1
(V"IJ'J)
udalilfil (G.!I~)
Adwr'll' Effl!cts
'lal'llmafil (lni\ra)
the corpora cavernosa just prior to intercourse. Penile injections caw.e pain and reduce the spontaneity associated
with pleasurable intercourse. These alternative therap ies
are rare today, though they may be used for patients in
whom phosphodiesterase-S inhibitors are contraindicated.
The PDE-S inhibitors do not cause an erection; they
merely enhance the erection resulting from physical contact
or other sexual stimuli by maintaining relaxation of the
smooth muscle in the penis and increasing blood flow. These
drugs are not as effective in promotingerectioll'i in men who
do not have ED. Despite cOll'iiderable research interest, PD E5 inhibitors have no effects on female sexual function, and
these drugs are not approved for use by women.
Two other phosphodiesterase-S inhibitors have b~n
approved by the FDA. Vardenafil (Levitra ), acts by the
same mechanism as sildenafil but has a faster onset and
,.. Prototype
Drug
"""""
I Slldenafil (Vlagra)
ADVERSE EFFEaS
Sildenafil iru by ~Iuing smooth musdts in W{orpori lal'MlOSi, thus allowing inaNst<i blood flow imo tilf penis. Tilf in{lNI~d blood flow rtlUm in a
firrntr ind Iongrrlasting maion in about 700M. of IIItn taking the drug. Tilf onsd of lion is 1I'1a1~~ rapid, less than 1 hour,and itstifrcts bst up 10 4hours.
Sildenafil bkKks 1h~ myrtle phosphodif,strrast-S.
Si1denafil ~ also UI~d for the trutrm~nt of pulmonary irt~rYl h)1ltlttlllion.
Blod:ing phosphodietm~-S in pulrrooary mrulu sroooth musd~ Glusts YoIsodi Lnion and rrouaion in irteri,l hyptrt~nsion. Tilf drug implO'/~s ~1Im:~ (apali!), in 1h~~ patient~
ADMINISTRATION ALERTS
INTERACTIONS
1)ug -1)ug: ("rnetidi~, H)'IIIromyc in, and~ew~l il:rNSe,..".m~of
PHARMACOKINETICS
IlerbaVFoo:l: GralM'fnir: j.ict ilKfNlfl thf plasma (OfI(t rlraticnl of IidmafiI and
mayaustad~ llIf!CtS.
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(hoplfl4/;
723
Assessment
SeJwlOysfulKtion
DisturbtdBodyl~
Dtr~nt Knowledge (drug
lherapy)
InstllKt the patient to rtport .ny sust.intd erKtion lasting 0YtI4 hours, or
an trtdion with .ignific.nt pain, to Ihe lItakh cart providtr oInd Ietk
prompt mtdic:.illrtalmtnl
(conrlnuefi)
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724
Unit .
T~ p;atienl shoold
H OME
&
COMMUNITY CONSIDERATIONS
lion all' being giYl'o 10 male patients n an ""r-ill(lI'oI sing tatt .Many hNlth ,,~
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structing the urethra, causing difficult urination. Symptom.. indud e im:reased urinary fH'quen~"y (usually with
small amounts of urine), inueased urgency to urinate,
postvoid leakage, excessive night-time urination (nocturia ), decreased force of the urine stream, and a st'nsation
that the bladder did not empty completely. The urinary
outlet obstruction can lead to seriouscomplicatiorusuch as
urinary infectioru or renal failure. In advanced cases, a surgical procedure called transurethral resection is needed to
restore the patt'ncyofthe urethra. BPH is not considered to
be a precursor to prostate carcinoma. BPH is illustrated in
", Figure 46.2.
The pathogenesis ofBPH involves two components: static
and dynamic. The static. factors relate to anatomic enlargement of the prostate gland. The gland can double or triple its
size with aging and cause a physical block of urine outflow at
the neck of the bladder. Thedynarnjefactors are due to excessive nwnbers of alpha,-adrenergic receptors located in
smooth-muscle cells in the neck of the urinary bladder and
in the prostate gland. When activated, the alpha,-adrenergic
receptors compress the urethra and provide resistance to
urine outflow from the bladder. The two mechanisms of disease, stlltiC lind dynamic, have led to two different classes of
drugs used to treat symptoms of BPH (Table 46.4). The
mechanisms of action of these drugs are shown in Pharmacotherapy Illustrated 46.1.
Certain frequently used medications can worsen symptoms of BPH. Alpha-adrenergic agents, which include decongestants such liS pseudoephedrine and phenylephrine,
may activate alpha,-adrenergic receptors in the bladder
neck , restricting urine flow. Drugs with anticholinergic
Choplfl46
725
0""
Adverse Effects
ALPHA,-ADRENERGIC BLOCKERS
alfuzo~n (lkwual)
daxalO~n (unhn)
......
tarrIIlbin (Flomil)
teralO~n (Hytrin)
5-ALPHA-REDUCTASE INHIBITORS
duta5lmdt(Avodirt)
PO;05mgltla,
Q fina5lmdt (PrOlCilr)
P0;5mg/tiay
~~' ---"!s-ll
.....,
U';M'Y
,..,.
Natrow<ld'-_--';:-1'1I
urtllhra
Hypertrophied
,.,
True proslale
~
,0,
Flgure46.2 Benign prostatic hyperplasla:(a) normal pronate with penis; (b) benign prostatic hyperplasia
Source: RIce. Jane, Medical TefmlllOkxjy with Human Aro.Jtomy, 5rh ed. O lOO5,p. 538. Reprinted by perml55/on ofPearKJfl fdumrion, Inc., iWr
Saddr..RIver.NJ.
~
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726
PHARMACOTHERAPY ILLUSTRATED
46.1 Mechanisms of Action of Antiprostatic Drugs
Static fa ctor.:
Gland . ,laogee under the
inA""""" of t _ _
Enlarged gland creat ...
~.AI_k>odinn '"
0,"",.
melaboliom.
choice for treating moderate symptoms of BPH. The selective alpha, blockers relax smooth muscle in the prostate
gland, bladder neck, and urethra, thus easing the urinary
obstruction. DOXllwsin (Cardura ) and terawsin (Hytrin)
are of particular value to patients who have both hyperten sion and BPH; these two disorders occur conUlrrently in
about 25% of men older than 60. A third alpha, blocker,
tamsulosin (Aomax), has no effe!:t on blood pressure, and
its only indication is BPH. Drugs in this class improve urine
flow and reduce other bothersome symptoms of BPH
within I to 2 weeks after administration. Primary ad~rse
effects indude headache, fatigue, and dizziness. Doxawsin
and tt't"awsin are not associated with an increased risk of
sexual dysfunction, but ejaculatory dysfunction has bet'n reported with tamsulosin. Reflex tachycardia due 10 stimulation of barorect'ptors is common with alpha blockers.
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Saw Palmetto
Saw palmttto (Sm:m rtptm) is ~ bulh, palm that ~ i1 t~ CNILllrrgions
of the IWIhrm Unittd SLlta The portion Uitd i1 ~pplemml> is t~ btrm of
thepl, nlMoll'ttun 2mili:mmtnlMl.lwpalml'uo in theho~thatitwilltft'at
BPH.likr fin.tn~ride, I.lWpilmttto is thought 10 btlp stop ~ usadt of proltill'd'fNljing tIIl)'mtI that may ClNj" BPH.1t also O(~ bilding ~l'I on the
proStlll' thataft' typical~ 0Upird by dilljdrotl'ltostelOOl' (DIU), an enzyme
that rna, trigger BPH.AItIKuj! ~I clinitalstudies have Suggtlll'd that I.lW
pammo is II~ as fillll\l'rid" i1 trrating mikllO moderate BPH and pr0duce ffo.m idvr~ eflKts, rww II'lNlth i1dkatl'l that it tu s00 brnefn in tINting BPH (~~ Kane. Shinotur.J, Neuhaus, Hudl'S, Goldberg, &AIvim. 2006).
5.iw~lmetto may (,JIM damage to the liver ~nd panuus,1G it is vital thu
1~ nu~obtain , thorough hNlth , nd ~pplrmtnlUII' history, .J ndadvill'lbt
~jient of in potential ad ..... rll' effect!.
Chopltl46
~ Prototype Drug
727
I Flnasterlde (Proscar)
ADVERSE EFFECTS
Fioalleride is well toleral~ and side ~ffemall' gentrally mild and lJaositnl
Finasttride UUIn v.rious type 01 II'lWI dysfunction in up 10 16% 01 patitnts,
ilKluding impoteoU', impaired fertility, diminishtd libido, and ~ula!ory d~
function.
(ontraindi cations: Tht oo~ (omraindic<llion is hypmtOSitMt)' to tilt drug.
INTERACT10NS
Dru;rDrug:IIIf with an tidIoIiIfr9iG may dKrNsf tIMo ~lIects finaruricIf. Ust of
fillilltlidewith 1!'I!lI:I1m1nt wil ~ in a rmtion in 1IIP ~lIects both ~
La bTI5II: YilIIlPI f(f lilT and p6W1f.!pf{iIK antigfo may bf drorud.
PHARMACOKINETICS
Onset: Maximum effrm may loll- 3~ mo
PNk: l- 1h
Halflift : S- 7h
Duration: 5-7 da~
Additional information on the alpha blocl(t'rs and a prototype feature for doxazosin are presented in chapter 2300.
Some patients are unable to tolt'rate the cardiovascular effects of the alpha1-adrenergic blockers. For these patit'nts.
the 5-alpha-reductase inhibitors offer an alternative. These
agents block an enzyme in the testostt'rone metabolic pathway, thus eliminating the hormonal signal for prostate
growth. The most commonly prescribed drug in this class is
finasteridt' (Proscar), which is featured as a prototype for
BPH. Th ...e agent. may take several month. to mrink th ..
size of the prostate; thus, they are not appropriate for severe
disease. The 5-alpha-reductase inhibitors produce few adverst' rlfects, alth ough they can cause se.'(ual dysfunction in
some patients.
Drugs for BPH have limited effectiveness and have value
only in treating mild-to-moderate disease, as an alternative
to surgery. Because pharmacotherapy alleviates the symptoms but does not cure the disease, these medications must
be taken for the remainder of the patient's life, or Wltil sur8"ry i. indicated.
KEY CONCEPTS
The numbered key conrepts providt' a succinct sununary of the important points from tht' corresponding numbered section
within the chapter. If any of these points are not clear, refer to the numbered section within th.. chapt.. r for reviEW.
46.1 FSH and LH from the pituitary regulat.. tht' secretion of
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72 8
Unlt l
Which of the following nursing assessments would beappropri~te for the p~tient rec~ivins testo.teronel (Select ~ll
that apply. )
I . Monitor for a decrease in hematocrit (Hct).
2. ARSS for signsoffluid retention.
3. Assess for increlsed musclt' mass and strength.
4. Check for blood dyscrasia&.
5. Assess for musdt' wasting.
II
Tht' patient with a history ofBPH is complaining of feel in g like he "cannot empty his bladdt'r." The nurse antici pates that the ht'alth care provider will order what
medication?
1. Tadalafil (Cl'llis)
2. Sildenafil (Viagra)
3. Ths\ostt'rone (Andro)
4. Finastt'ride (Proscar)
A patient is given a prescription for finasteride {Froscar}
for treatment of benign prostatic hyperplasia. Essential
teaching for this patient includes: {Select all that apply. }
I. full therapeutict'ffectsmaytake 3 t06 months.
2. hair loss or male-pattern baldness maybean adverse
"''''.
EXPLORE
~~------,
MylkJlYIgKd ~ iwr one st~ !of onl ine chapter reoiew matenals I!I1d
resouroos. Preporo for success with ad!ilflnll NCLeo:-style ~ice
aClMtl~,
www.mym."'g kill:om .
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U NIT
The
Integumentary
System and
Eyes/Ears
CHAPTER 47
CHAPTER 48
CHAPTER 49
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DRUGS AT A GLANCE
PHARMACOTHERAPY OF HYPOCALCEMIA
CalciumSupplemenu fJt1Itll4
LEARNING OUTCOMES
Alrer reading this chapIn', the student should be obit to:
pqJtJJJ
Q caklumsolts (l!JgtlJ4
2 . Identify the rec ommended dietary a ll owance and the normal serum
level s of calcium.
3 . Explain the roles of parathyroid hormone,calcltonln, and vitamin 0 In
maintaining cakium balance.
4. Explain the pharmacotherapyofhypocalcemla.osteomalacla,
osteoporosis, rickets, osteoarthritl ~ rheumatoid arthrltl~ and gout.
S. Otoscribe the nurse's role in the pharmacologi c management of
disorders related to bones and joints.
6 . For each of the drug classes listed in Drugs at a Glance, know
repre-sentative drugs, and explain their mechanisms of action, primary
actions, and/or important adverse e ffect s.
7. Use the IlU"sing process to care for patients receiving drug the rapy for
bone and joint disorders.
DISEASES pJtJJJ
Vitamin DThmpy ,.114
Bisphosphonates ptlJtlJ6
O o/endlt>flare(f0s4r1l<U) ".111
Cakitooin IUIllll
PHARMACOTHERAPYOF JOiNTOtSORDlRS ,.JJ
Disuse-Modifying AntirlltumlllK Oru95
pqgtUl
o hydroxy<h/oroqu/M (PIoqINflIQ , .m
\ki( Add Inhibitors ,.U4
KEY TERMS
mrtegoutyarthritis (XI/tJ44
utoantibadies fJII9f741
bisphosphonates /#It 136
bone df,po~tion Ili9t JJ1
bone morption (IIl9t l1J
GJkiftGol , . J1J
Glkitoni. p!IIItlJJ
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nkitriol ~7Jl
cholKaldMroi tuJf 7Jl
diINIP-rmdif-,ing i ntimfumatic drug (DMARD)
""m
9001
piI}t UJ
~,pfnricfmi.J plllJl'143
Olttoarthritil(OA) fJiJ9tl4l
olttomalacia (JQ9t Jj)
olttoporosb (JI)JtlJS
PIgeI's diSfHf (llJ9tl)l
rMlmltoid arthrim. (RA) pogt 141
5fietti"ft fS1nI9fn rtplor modIILltors (S ERMs)
"",m
73 1
47.1 RoleofCalciumandVitaminD
in Bone Homeostasis
affect
II
This chapter focuses on the pharmacotherapy of important skeletal and joint di sorders such as osteomalaaa, osteo-
Calcium is the primary mineral responsible for bone formation and for maintaining bone health throughout the life
span. This major mineral constitutes about 2% of our body
weight and is also critical to proper functioning of the nervous, muscular, and cardiovascular systems. To maintain
homeostasis, ca lcium balance in the body is regulated by
parathyroid hormone ( PTH ), calcito nin and vitamin D, as
shown in ~ Figure 47.1.
Se.:reted by the parathyroid gland" PTH ,timulat.... bone
cells called o5trodasts. These cells accelerate the process of
Paratt.;roid gl ands
o
a
o
'"
in tho bIoodst",.m
Thyroid gland
o..c",ased absorption of
CIIIciIm in """,II intestine
'"
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732
~akilulli".
r
Skin
Calcilediol
(inlermedialelorm)
PT"
Parathyroid glands
Calc~r iol
(ac~ve
vitamin 0)
Increased absorption
01 calcium in
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CNplfr47
The primary function of calcitriol is to increase calciWll absorption from the GI tract. Dietarycalcium is absorbed more
efficiently in the presence of active vitamin D and parathyroid
hormone, resulting in higher serwn len~ls of calciwn, which
is then trall'iported to bone, muscle, and other tissues.
The importance of proper calcium balance in the body
cannot be overstated. Calcium ion influences the excitabil~
ity of aU neurons. When calcium concentrations are too
high (hypercalcemia ), sodiwn permeability decreases
across cell membranes. This is a dangerous state, because
nerve oonduction depends on the proper influx of sodium
into cells. \I/hen co.lcium levels in the bloodstre"m "re too
low (hypocalcemia), cell membranes become hyperex~
citable. If this situation becomes severe, convulsions or
muscle spasms may result. Calciwn is also important for the
normal functioning of other body processes such as blood
coagulation and muscle contraction. It is, indeed, a critical
minernl for life.
47.2 Pharmacotherapy
of Hypocalcemia
Hypocalcemia is not a disease but a sign of underlying
pathology; therefore, diagnosis of the cause of hypocalcemia is essential. Many factors can cause hypocalcemia.
Lack of sufficient dietary calciwn and/or vitamin D is a
common cause,and one that can be eas ily reversed by nutritional therapy. If hypocalcemia occurs with normal dietary
intake, GI causes must be examined, su<:h as excessive vomiting or malabsorption disorders. Chronic kidney disease
may cause excessive loss of calciwn in the urine. Another
etiology for hypocalcemia is decreased secretion of PTH, as
occurs when the thyroid and parathyroid glands are diseased or surgically removed.
Drug therapy is occasionally a cause of hypocalcemia. Blood
transfusions and certain antioonvulsants such as phenytoin
can lower serum calciwn levels. In addition, overtreatment
with drugs used to lower serum calcium can result in "overshooting~ normal levels. Some of these include furosemide
(Lasi."l), phosphate therapy, or bisphosphonates (see Section
47.4). Of special concern is long-term therapy with corticosteroids, which is a very common cause of hypocalcemia and
osteoporosis. To help prevent oorticosteroid-induced osteoporosis, patients should receive daily supplements of calciwn
and vitamin D.
Signs and symptoms of hypocalcem ia are those of nerve
and muscle excitability. Assessment may reveal muscle
twitching, tremor, or abdominal cramp ing with hyperactive
bowel sounds. Numbness and tingling of the extremities
may occur, and convulsions are possible. Confusion and abnormal behavior may be obserwd.
Unless the hypocalcemia is life threatening, adjustments in
diet should be attempted prior to initiating therapy with calciwn supplements. Increasing the consumption of calciumrich foods, especially dairy products, fortified orange juice,
cereals, and green leafy vegetables is often sufficient to re~
store calcium balance.
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733
If a change in diet is not practical or has not proved adequate for reversing the hypocalcemia, effective and inexpensive calcium supplements are readily available over the
counter (OTC ), in a variety of formulations. Calcium supplements often contain vitamin D. Severe hypocalcemia requires the intrnvenous (IV) administration of calcium salts.
Calcium has two major forms: comple:wd and elemental.
Most calcium supplements are in the form of complexed
calcium. These products are often compared on the basis of
their ability to release elemental calciwn into the bloodstream. The greater the ability of complexed calcium to rele"se element,,1 c"lcium, the more potent i. the .upplement.
Table 47.1 lists calciwn supplements.
PHARMACOTHERAPY OF METABOLIC
BONE DISEASES
M~tilboli,bonfd il~I!(MBD) is a general term referring to disor~
derscharacterized by defects in the structure of bone. MBDs
are caused by abnormal amounts of the minerals or hormones required for proper bone homeostasis, such as cal
cium, phosphate, vitamin D, or PTH. Some MBDs have a
genetic etiology while others are iatrogenic, caused by cer
tain drugs and therapies.
47.3 Pharmacotherapy
of Osteomalacia
Osteomalacia is a MBD characterized by softening of bones
due to demineralization. \Vorldwide, the most frequent
cause of osteomalacia is a deficiency of vitamin D and calcium in the diet.1bis risk factor for the disease, however, is
rare in the United States because many processed foods in
this country are fortified with these vitamins. In the United
States, osteomalacia is most prevalent in older adults, in
premature infants, and in individuals on strict vegetarian
diets. The term osteomalacia is usually used for adults with
this MBD; if it occurs in children, it is called rickets.
Signs and symptoms of osteomalacia include hypocalcemia, muscle weakness, muscle spasms, and diffuse bone
pain, especially in the hip area. Patients may also experience
pain in the arcru, legs, and spine. Classic signs of rickets in
children include bowlegs and a pigeon breast. Children may
also develop a slight fever and become restless at night.
In extreme cases, surgical correction of disfigured limbs
may be required. Drug therapy for children and adults consists of calcium supplements and vitamin D.lnactive, intermediate, and active forms of vitamin D are available as
medications. Drugs used for these conditions are summarized in Table 47.1.
The daily vitamin D needs of people vary depending on
how much sunlight is received. After age 70, the average recommended intake of vitamin D increases from 400 units!
day to 600 units/day. In severe malabsorption disorders,
patients may receive 50,000 to 100,000 Wlits/day. Because
vitamin D is needed to absorb calciwn from the GI tract,
734
UnII'
Th~ IntequmeotorySY't~m
arid E)o'''Em
Drug
Adverse Effeds
calw mchlorid/,
administooion.HYDma!rnii (!WN~nm.
Inhargy hNda(iIt inortlia.oau~Hnd
vomit"ng,ioomtd uioation and tliDtl
wrtrabmbj y rdjKam! roohnjpn delirium
--
VITAMIN 0 SUPPLEMENTS
Q uldtriol (Cildjft,Roultrol)
dIoIKaIdftrol (DtluD)
dih)'ltotadlysterol !OHT, H)"literol)
doJo:t.lkifffill (lIKtorol)
I Calc!um Salts
ADVERSE EFFECTS
0r.J1 U1D1n products JI"I' sale when ultd as ml"l'('(m ~ most oornmon . dYe!w
~t ishypmakrmia,caultd b)' taking too mud! ofthissLppltrntntS)Tl1ptoms
01 h)1lOUhmi.o ino:lud.d""""n.... IHlur<JII, W<'Jkrws<, h...da.ch.,a",,",,".,n.luIN and vomiting. nc:1N1td urioation, and thi~t.lV administrati:m of cak:iJm may
c.JUII' hypotmsion, brtdylardi.o, dysrhythmits, and cardiac: anm
Contraindirations: Calcium salts art rontraind"Kiled in )lttirnts with I'tntriruIt r fibrillttion, meu stttic: bont (.rx~ ~ 1"1'001 I "kuli, or hypertak:tmia.
ADMINISTRATION ALERTS
INTERACTIONS
I)ug- l)ug: (OOOI"fm U\f with dgoxin irKrNsH tbf rill; of dysIhyttmias.
Mq.nivm mq mpetf for GI absorption. CakMn deufNs tbf abIoIpIion of
tftnqOni'S. CakMn rniI'f.nagon~ tbfffftm ofukUn manntl bIcKIIfo.
lab Tet!:Ukium may iIKrNIt Yalues for blood pH and ~urn cakium.l! may
d!oau\.! IffIIII ~f iOd poIiI\!iiurn lMk,and~mand urilarymagnNJrn.
PHARMACOKINETICS
LibraryPirate
Trmtmfnt of O~rdosr: Mfasu 1"1'1 ma~ br u bon to lI"I'at "rditc abnorm. litirs
uultd b)' the IfIUlting hyprrtakernia.
Rtfer 111 MytmJnqKI fer a MnJng Procell FooII Ip/It 111 1M ItuiJ.
..
73 5
ADVERSE EFFECTS
Vitamin Dtht"py m,y Ut/Sl' symptoms ofh)'ptluktmidllel~ indudt p.llp~
t.ltionl. anorffl.!, n'UlI'a, vomiting.. blurl!d vilion, pootophobi', constip"ion,
,bdorrin,1 mmpl, metallic IaStt, hu!bcht, ....,.,knns, dry moulh,lhirs/, in~,1I'<i urin"ion,and mUldt or bone p,in.
Conmindimions: This drug should not be giYen to !!'IimU with h)1ltKalcrmia orwith MIltner of vi/,min Dtoxicity.
INTERACTIONS
DrurOrug: iliilidt lilntiG may eoIIanao 1M ffftm of"IiUmiIl D, OOIing
h~ Too mlKhvitamin Dma)'GIUIf d)Vfl)1hnin i1 patimts rtcei"lilll]
digolin.~antacidsoc~ts!hcQd not bf 9NerI <roaIIIfIltly dJt
10 tIw inoN\.ed rill; of~permag~
"
,,0
~
0
"
PHARMACOKINETlCS (PO )
Dnll't:2- 6h
~k :ID-12 h
(lUll'
Duration: 3- 5 da)'i
h)'pI'IakfllN.
IItI'tf rc M}NurJlIIgKJ/ fr1r Q NurlIrrtj I'rDm.! fooJs lpI(lk 11/ rills drug.
47.4 Pharmacotherapy
of Osteoporosis
...
Normal bone
homaotaois:
Ooposilic:n"
msorpbo~
Menopause
High alcohol or caffeine conswnption
f:lasorQ'.~
Anorexia nervosa
Toba cco u,e
Physical inactivity
Testosterone deficiency, particularly in older men
To body
(b) Low calci..., inlake
LibraryPirate
tl depoSifbq
...
Os1eopor<ltio bone:
Resorption exceeds
deposition. Bone
beoo"", ~ Iragilo.
,~
i
0:
;0 """
~
F/qure 47J
"~
736
UnII'
BISPHOSPHONATES
Many drug therapies are available for osteoporosis. These
include calcium and vitamin D therapy, estrogen replacement
therapy (ERT), estrogen receptor modulators, statins, slowrelease sodium fluoride, bisphosphonates, and calcitonin.
Teriparntide (Forteo) is a newer drug for osteoporosis produced through recombinant DNA technology that resembles
PTH. Some of these drug classes are used for other bone disorders or for conditions wtrelated to the skeletal system. Selected drugs for osteoporosis are listed in Table 47.2.
PHARMFACTS
Osteoporosis
Ihttoporolil is tht most prevalent bOIII' di50rotl" in Mttriu.
On an annual ba~,28 millioo p.ltienU urtither diagn05td with
ostropolOlis or(onsidertd to bt at mlt'mt rille for this disordtr.
Womtn ,It' Iourtimts mort likelytode-.oelop ostroporosis than mtn.
M.nywOlllfll with ostroporosis.1t' of postmtnoplUlaI q.
After the "91' of SO,oneol t~trytwo womt n.nd oneof t'ltry t ight mtn
alt' likely to dtl'flopa Iri(tult' R'lattdto os1topOrosis.
Drug
Adverse Effucts
HORMONAL AGENTS
oro
i"irionsire
Aniph'llaxi!
tit"
HvpOQI(fOlia, ltinrm
Brml !MjD
~
Subwtallfous;20 mC9fday
Synwpt angina
BISPHOSPHONATES
OIiNpOr01i1: PO; , - I0 I119iday
Q altndronatt lFosamax)
I'O;B I119iday orone 1,IHng ubltt ]1ft" mo, tal:.m on tht samt
dar~t.dJmo
panidronatt l,lndia)
....
riltdronatt (,l,aontl)
tiudronatt lSWd)
~--c'c'
::c(::::"); ~mg ~ngIt doll' i1fwd Irm at INnIS min'--_ _--'_ _ __
LibraryPirate
CALCITONIN
Calcitonin is a hormone secreted by the thyroid gland when
serum calcium is elevated. It acts in direct opposition to
PTH and vitamin D. As a drug, it is approved for the treatment of osteoporosis in women who are more than 5 years
postmenopausal. It is available by nasal spray or subcutaneous injtion. Calcitonin increases bone density and red uces the risk of vertebral fractures. Adverse effects are
generally minor; the nasal formulation may irritate the
nasal mucosa, and allergies are possible. Because the parenteral form causes nausea and vomiting,it is rarely used. In
I Alendronate (Fosamax)
ADVERSE EFFECTS
Adl'fll! tfIf(1S of .ltndronate a~ diarrllta, ronstipation,lIatultlKf, nlusra,
wmitilg, mmllic: Iastt, hypouk~mia, hypophosphlltt mia, abdomin.1pain,
dyspepsia, anhralgia, myalgia, ~adoK~, and fillh. Pathologic: frac:turl'l rray oc:cur if tilt drug is taken Iongmhan 1 mornhlor in mesof mronic: O'/erdoW'.
Contra ndiu tions: Contraindication I indude patitnts with ol1M1maooa, abnormaitirs of th~ l'IOphagus, or who have hyprrsfnsitiYity to the drug. Cau
tion IlIouki bt UI~d in patienll with ft'nal impainn~n~ htan failurt,
hyptrp.osphat~mia, lim diW'.ut, fever Of infKlion, oKti'll' Uppl'l GI problem ~
and plfgnanC)'.
INTERACTIONS
Drug-Olll!l:Ukium, iroo, iIIltacick (ontailing alminum 01 magllNlm. aoo ooain
ninrr.1I~ n me..ewithtlw abIorption of alMdronatr ollld h.m tIw
pounti.ll to ~ i6 flf~s.lNwithikohol!lla1 incrNsr tIw rill: of
osteopcrosil...-.l (;!(M IjNriI: ilitoiHn
libTI51I:Unmown
ADMINISTRATION ALERTS
rake on an tmpt)' ntmach with plain wate~ pft'ftrabl)' 2 hours btfoft'
breakfast.
Rtmain in i n upright position for at Itm 10 minutl'l aftrr 01 doW' and until aftt r the first food of t~ day 10 !!duc:t ~lOphageal inilollion.
Herbi Hood: The dirt mtIIt haveidfquat! amounts of '/itarnil D, cakium, oIIId
phosp/utl'S. ukium oIIId food (~Iy da' ypro.ilml rfducralMdronate
Plf9nalK)' megCIT)' C
PHARMACOKINETICS
OnSl"t:1~wk
~k:l~mo
737
Uwkorlllm
LibraryPirate
_'m
e1p1'lt~ tfI!'(~
and rray be
"
738
Assess me nt
"""l
c..
."'
Implementatio n
Interve ntio ns and (Ra tio na le5)
hl,ring lberl~utic effeds:
Rtvi~ tilt diNry hiltorywiththt patitflund discu~ food _Itt optiom
for{orrtaing IIIr ak:iJrn or mmin OdtficirllC~ Enmurigt tht ""titnI: 10
~t . hNItIrf ~irltylt of _lItd physil.1 I<IMty,~tt ~
txjIOSurt, limitd (. fftinr.and!Oda incaR,Jnd limiMd Of~imioal~ .mhol
mmumption.(Adtqllillt .mount! 01(., ri1amin O. il.l M9Jrt nmItd for
bont hr.Ith.Any dtficitocits sIIould IItmlfKttd btfort bispholphollilft
irt laM ~It lUll txpOiUrt m'r mill in vit.nWJ 0 formation.
ElKmNt !Oda Ofaffloiot inul::t may inuNsrthr risk ofO!it~rosii.)
LibraryPirate
739
Tta{h tht ])iItirm appropriate .dmin ~lration guidrlines. Ensu~ that the
patifllt is. blt to rf main upright.fter .dministration il bi.pho!;phon. t..
.~used.
ImtMt the patirm to immediat~1y ~port ill)' nrw onSfl of naus~. or i ll)'
ilKl"N,ing or !eI'm dlrSt or ilbdominal discomfon or pain.
ImtMt th~ patirm on the r"ftd to return ptriodiully for lab work.
ImtMt the p.tirm to immediattly rt'port ,ymptoms of lrypoukmlia
(mUlIt 'pa snu, fi{ialgrimacinQ. irritability, hyper-ft'fltJe1) or
hyperuktmia (in(rNstd bonr ])ain, iOOft'lia, na!Ma, vomiting,
(on >lipation, thirs!, Itthargy, fatigut).
ElKourq til!' patitntto ilK~ut fluid intake loll offluid per diy, divided
tfJroughoUI lhe day, but '\'Did highly {,)f!tin.ttd btvrrages and ~l{~sivt
soda inuke.
Tei{h the ])iItirnt to{ominue uking the drug therapy rt'!Jllarly to fIl'U~
fUll tfit{u. Therapeutic: ft'Sponse maytake 1 ta 1 momlrs . nd tfleru
(ontinue after tht drug has bet-n discontinued.
Thr p.tirm should br ablt to stair the reason for thr drug;appropriate
c10seand schtduliOC);what .mlSe rfINu to oIurw far and when ta
report; and tht imic:ipat~d itngth of mtdiution therapy.
."",1
Evaluation of Outcome Criteria
haluatt tht rfito:tie0e5' of drug ther~py by mnfinniOC) that ])atirnt go;alsand Hprcttd oukomrs hiyt bten met (set Planning").
LibraryPirate
74 0
\\bmen of Caucasian and Asian Anman de!!mt haY!' a hi9:"otr ~~ 0101teo~ than !host of African American de!!m~ ahhouijl po!Imenopal/l<ll
women ,lI"e ~ ~higlwst rilkin allethni:9roups.hisimportlnttomnem~th~
men also an dtYelop this dwse.
MIl though mNi:atDnS <Ill' n-ailable to hah bonedtttmmion,pmoention
u,.f1tablilhingand maintaining a healthy liflostyleis the Uyto~og 0\tI10pomis.L\Jring dliklhood ilnd ~1Ke. the 10m Ihwkl be on llIikling bone
mass.Chikllt'fl s/wld be erJ:lUaged to Nt bods h9J in akUn and vitallin 0.
~ ~1iIrt,<, and avoid !IIIOkiIg and mmiYe UII' of akohol. [).ri-,g iduhhood,tIr f00/l5houki beon !Nintlining bone mmand rontiruing hNhhy Iimry ardemcis.e habits.Vitamin ~ maybe tlktnon theadvicf,ofthe
heahh rare proYidtor. ~tmmop;IUliI WOIIII'n shtUd forus 00 pIl'YI'ntmg bone
ms.ln aO:lition to maintaining a hNlthy lifestyle. patienn !hd:l haY!' bone dtn>itytfSUandmoukidisrussthepossibilityolukingmediutilOto~ortll'at
osteoporol~ with their health (,lll'
prom
~ Prototype Drug
JOINT DISORDERS
The M"Oing nurse on drty <ldministm mediutDns at 10:15 p.m. When <I
nuBl' mten~. Brown's room,Ms. Brown is alll'ady in bed and falling ilftp.
The nuBl' gent~ shakrs her <l nd says, ' l h.M)OOr 10 p.m.mediutDn~ Ms.
Brown. Ahhough the pilient awa bons, she is not fully <lwa boo Tht ruBe hands
htr tht mNiution <lnd a gl.m of waif r.Ms. Brown l.ikf"l the mediutDn and
qui:kly ll'Iums to llfeping.ln lI'aling..tht nUBe noti:f"I the I0OIII rumber and
Il'alilflthat mediution was just giffi to ~.(rown, who is in a room down
the hall from ~.Brown. Wh~ should the nuBl' 11m dollf dilFell'ntlyl
Sn~xOAlrll1tjjjljl}t!ltrlalllm.
I Raloxlfene (Evlsta)
ADVERSE EFFEaS
Tht most {ootmon adveBf e1fecu of ralol:ifme therapy all' hotllashel, leg
{ram pi. and Wl'ight gain. ~s {ommon effects in{kidt feYfl, archralgia, dtpll'lsian, insoot nia,dlet pain. peripht ral edtma, declfased IfIIIm {holl's1flOl naulI'a, vomitin~ flatulen{e, {)'Stili!, migr<li~ lItada{~ IkJlibo symptOlll~
endometrial disordlo~ brNSl pain, and 'liginal bletrling. Ralol:jff llf has two
bla{k boxwamings.FiBt it may iOUNII' the risk fordeepvtin thrombosisorpulIOOnaIY embolism. mood, use of ralcoifene may in(ll'ast tilt risk ofdNth dU!'
to mob in women with {oronary hean disull'.
Contraindications: This drug is <omraindiuted Iklring lacution and JIIl'9oaocpnd in WOIIII"O who may bt<OIIIe Pll'9nam.Patitnu with a history ofvtOOIIS throm botrn bolism and thOIt' hypeBl'ositil'l' to ralolifflll' should not take
this drug.
ADMINISTRATION ALERTS
GiYt wilhorwithoutfood.
Pregnancy category X
PHARMACOKINETICS
Onset 8 Wl'eki
Ptilk:Unkrnwn
Hall~i~:27-33h
Duration:Unknown
INTERACTIONS
Dtamfd raloDlI'fII' ibIoIptioo wil ~k from (OOQIIfi( Ulfwitha~lin
dJJIeItyrami~. list of raloml'lll' "";!h othtr higbt, proIm.boIIid druos fi~/@fl.
indornethacil, dimpam,etc.) may intelfflf with bindi"lg sites. Pilients should oot
t.Jkf {boItsteroI1owHi1llj dnq; IJ I'IIrOljl"O rtpI.t!:flllfllt1llfr~ {OOQIIl'Otlywith
thislMdicaion.
Lab Tl5Is: iLllmifl'Of iMJNII'I Ullfl of ipolipoprotein A,. anir:oSienid.ti1cJir19
iIIId thyrOIinHindilllj gIobuIin.ltlNY deuNIf"lillllfl of dloII'IIfId,
1lKi00000,apoipoprotein B,iIIId IipofxotHl (a), ukim,~t.. total protein,
andalbumin.
~il,
HtrbaVFoo:J: 8Iid at.o\h has I5IroC]I'I1ir: flfeas and IIW1 in~ with thf aaions
of riklrffM!'.
LibraryPirate
741
PHARMFACTS
Arthritis
8~twefO 10 and 40 millioo propl!o in t~ Unit~d Slates ,1I~ aflectrd by
OIteoarthritis.
After igr 40, m~ than 9O'Jj, of th~ populuion Iwvr Iymptoml of
OIteoarthritis in major'Mightburing joints.Ahr 70)'UB of age,almost
,Upatients IwVfsymptomlof osteoarthritis.
Of the WOrld'l populuion, 1% hil'f rlwumatoid arthritis, which roost
often alfh puitou beIWffiI 30 and SO ),!,aB of age. Womenart thr~
to rll'f times roo", likt-ly to dtvelop rlwumatoid arthritis than men.
a..-. 1"" .nd 3~of tho U.s. popubtion.", .fftctrd by gout. Most of
thr pnirou,,,, men bHwffn the'lIH oflO and 60. Most WOmtn ,'"
affffifd after menopault.
47.S Pharmacotherapy
of Osteoarthritis and
Rheumatoid Arthritis
Arthritis is a general term meaning inflammation of a joint.
There are several types of arthritis, each having somewhat
different characteristics based on the etiology. Coutyarthritis is presented in Section 47.7.
Nonpharmacologic therapies are som etimes effective at
relieving arthritis pain. The use of nonimpact and passive
range-of-motion (ROM ) exercises to maintain flexibility
along with adequate rest is encouraged. Splinting may help
keep joints positioned correctly and relieve pain. Other therapies commonly used to relieve pain and discomfort include
thermal therapies, meditation, visua lization, distraction
techniques, and massage. Knowledge of proper body mechanics and posture may offer some benefit. Surgical pJ"O(;edures such as joint replacement and reconstructive surgery
may become necessary when other methods are ineffective.
OSTEOARTHRITIS
Ostl!Oarthritis (00 is a progressive, degeneratiw joint disease
caused by the breakdown of articular ca.rtilage. It is the most
common type of arthritis. Weight-bearing joints such as the
knee, spine, and hip are most frequently affected. Symptoms
include localized pain and stiffness, joint and bone enlargement, and limitations in movement. OA is not accompanied
by the severe degree of inflammation associated with other
forms of arthritis. Manyconsider this condition to bea normal part of the aging process. A patient with OA is shown in
~ Figure 47.4.
The goals of pharmacotherapy for OA include reduction
of pain and inflammation. The initial treatment of choice is
acetaminophen because it is inexpensive and relatively safe.
For patients whose pain is unrelieved by acetaminophen,
JluJlskruiJ~1 ~Jlti-iJln~llmJ~tury w-uK"' ( NSAIDs), illduJillK
naproxen and ibuprofen-like drugs, are usually given. Because high doses ofNSAIDs can cause GI bleeding and affect
platelet aggregation, patients must be carefully monitored.
Aspirin is no longer recommended because the high doses
needed to produce pain relief in OA patients may cause GI
bleeding. Tramadol (Ultram) has become a popular drug for
LibraryPirate
RHEUMATOID ARTHRITIS
Rheumatoid arthriti, (RA) is a chronic, progressive disease that is
characterized by disfigurement and inflammation of multiple
joints. RA occurs at an earlier age than osteoarthritis and
has an autoimmune etiology. In RA, autoantibodies caUed
rheumatoid factors attack the person's tissues, activating complement and drawing leukocytes into the area, where they att~<.k th" ""US uf th" 'y"uvial JJJ"JJJUrdlJ"" ~llJ uluod. TIll'
results in persistent injury and the formation of inflanunatoryfluid within the joints. Joint capsules, tendons, ligaments,
and skeletal muscles may also be affected. Unlike OA, which
causes local pain in affected joints, RA truly produce systemic
manifestations that include infections, pulmonary disease,
periClrditis, abnomlal numbers of blood ceUs, and symptoms
74 2
Flgure47.5
TABLE47.3
Dru,
ab.Jtac.~
(CRno:g)
~~mumab(Humira)
anakirn (KiImI)
mtolizumab ~ (GmLl)
l/KoI~~rmjrioofire(poin,e~
",y.Igiq), ~'JQ1Ophorynqiti>
hod . ,followtd by
Adverse Effects
goIim.mab (Sirrponi)
-'"
ilfliximab [RemK.ldf)
lttIunornidt (AraQ)
ri\Ul(imab (R~uun)
disord~n
IIeJId~cIrf, g/oJ'iitis,
Q hydrox)'dJloroquil~ (~I)
M~!!!RI1!nli2!l,~tOJ:!!;i!y.!):mm!!rulfrr~t!\'~
LibraryPirate
(Enbrel), anakinra {Kineret ), and the recently approved certolizumab pesol (Cimza ) are newer therapies that block
steps in the inflanunatory response. The biologic agents appear to be effective and relatively nontoxic, although they
are more e.lpensive than first-line therapies.
The choice of specific DMARD depends upon the experiences of the health care provider and the response of the
patient to therapy. Therapy often begins with hydroxychloroquine (Plaquenil ), methotrexate (Rhemnatrex, Trexall ), or sulfasalazine (Azulfidine), because these drugs have
the most research-based evidence for reducing morllllity
due to RA. Gold salts, o-penicillamine (Cuprimine), azathioprine (lmuran), cyclosporine (NaHal ), and cyclophosphamide (Cytoxan) are used as second- line drugs because
they are more toxic. Biologic therapies such as etanercept
~ Prototype Drug
743
I Hydroxychloroqulne (Plaqueml)
ADVERSE EFFECTS
ADMINISTRATION ALERTS
INTERAalONS
Dru;rDrug: AnOOds rontairing aUrinlll1 or crrq.nium may prt\'au abIoIption
01 hydrorydlloroquillf. Hydroxychoroqvinf may OOUlf tilt ri!Ir of Ij\'fl to~
wIIfn minisleI!CI with ilfpatorOIil: drugs:ilkohol U\f sboUd be eliminatPd during
thtrapy. TIii ~ aID may N:t to inmastd dgmcin k>wk. iOd mayintalm with
tlltp.atil'Ofire\jlOO5C' 10 riiM!! voKCillf.
ra~atthes.i lll!'tilll!'f~ryday.
Administerwith milk to dtclNSf GI up!et.
Slorr drug in saft place,as it is l'l'IytoxK to children.
PlI'gnillK)'U1egoryC
liIbTl5u:Unknown
PHARMACOKINETICS
On~ : 4~ weeks for Imirntumatic
rf"lllOIU
~k: l ~lh
LibraryPirate
744
I ColchICine (Co/erys)
Cokhic:iDl' is <I natur<ll prodKt obtain~ from thr autumn (fUS that has been
thr trlditiorul or,1 drug of dlOicr for thr trNlmtnt of <lrult gouty arthritis.1t
hn ~n lMd forc~nturifs. ,rod was appro.'td by the FDA in 1919. k is molt riflive ~ taktn within 24 hours alter the onset of symptom5.The drug redum
inftamm<ltion mociated with acute gouty arthritis by inhibiting the \)'llIhesis
01 mic:rotubults, 1U~lular Itructu~ ~ponlible for helping whitr blood (rlls
infiltrate an arN.Although <okh ic:iDl' has no anllgtlit properties. patitnts fIptritn ' pain ~Iiel dut to the red uuion in infl.1 mmation.lt m<ly ~ tI ktn to pit\'tnt or trut acute gou~ often in combirution with other uric: <lad-inhibiting
ilgtnts.ln 2009, cokhicinr brarne thr first druglppflfl'ed by thr FDA to t~'"
II milialMrditerTall!'an ~, (FMf ), I hered itI ry disorder ch<l r<ICterizfd by <lCute
inflammuion loci arthritis.
AOMINISTRATION ALERTS
ADVERSE EFFECTS
Adwrv rfieru SIKh <1\ nollrl~, I'Omiting, di,rrhe", 'IIO~Ua, and abdominal
pli nart cornmOlllt thr begin ni ng 01 thrr<l py. The drug m<ly (ILIV boor mlrn:M
INTERACTIONS
i)ug-On.og:eona.rftII!6r wkhHSAIDs n-..y 100_ tilt risk olGls~oms.
WdidDl' may fnlit additM bont INIIIl'II' tuxidty with (Jdo!.poriflf,
phefl)"looWOOf,MId othrr lkug!;tlwt~ atlKI bofIfmarrow.El)'\I"Iomtcin
may imaIt serum (okhidDl' Irwell.loop di.ntics lNy !lrcrflllf (okOODI' KIt<!\.
AkdlOl or prodoos that COIItail akohollNY QUSf Win r.sllts ~1Id rfSIJI ln ~itNt
INtr damage.(okhidnt 1M)" InuNlt SffISitl"lity to (NS di'pm:slts.
lab Tets: {okhKi"lr may In1Prlt~ with Iriny lIeroid detHm ina!;oos, am rn.y
~-
PHARMACOKINETICS
On'itt:l1h
~a k:O.5-1h
Hal f~ ift:l .HOh
Dmtion: Unknown
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Tru tmfllt of O'/froos.: Ovrrdose (induting lCCidfIlul ifl9tStiln d autumn (10CUI) may<JI.M _~GI d~trffi, shod, pa~ttsis. delmm, rtspi"<IIorY fiikt~,and
<!Nth. Tre.lIment ~ l)TI!p~ticloci lNy Jd.degutric Llvagelrod htmodialysis.
IIt(rf S/MyMIJIngK' fot~ tmJrIgl'rol:sfoonsptc~ S/ 1M /trig.
TABLE 47.4
"n"
alopurinolllqlt1in.I)'loprim, olhm)
Adverse Effects
(okhicin ~
745
(Cokrys)
ltIioomii Ihf!!!!lt!o;!ro~,",a!!!ljgranuIoMOIis.
~ere diarrhea. fS!hroloxidty
friHlXOItlqulorK)
PO;4G-SOmgOlKedaiy
MwJlfl,rr15ir
r-
suffinp)'l<ll_ (MIUlallt)
I.ildi5Im!,roJir
Asse ssment
LibraryPirate
746
UnII'
Ey<>"rEars
Inm'.m Huid intake to 2 to4l porr day.Monitor urinr output and obtain
porriod ic: urinalysis. (llKft'a5f<t fluid imake in(INs~ uric ilid t);{rtlion and
prMnll urinary uric: add (rystal formation or rmal (akuli.)
Continue to roonitOi !fIUm <lnd urinary uric acid ItYrls and Mtt
improl'tl!ll'llt in I)'mptom ,of arult inflammation, gouty toph~ and
improYed mO'femrrtt with Itss pain 01 afittled joinu. (As uric <lcid ItYeis
decft'alt, inflammation due to uric acid crystals ,hould improvt.)
Monitordaily ~ight and urina l)' OUIput (Uric acid mrMion may (.11M
urate ayml formation in the kidnt)'! with IrIUlting rl'nal impai,mtnt Daily
wtight is an muratr mNSu~ ofOYefall body fluid wkJmt.)
ItO~.)
The patient should lit ablt 10 state tilt rl'.IlOn for thedrug;approprialt
~ and ItlltdJling;what adYmt rflKl! to obSl'M' for and wiMon to
ft'pon;and liMo anticipated length of mtditation tiMorip)'.
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747
Chapter REVIEW
-
KEY CONCEPTS
The numbered key concepts provide a sucdnct su mmary of th e Important poin Ts from the corresponding IlUOlbcrt.-d section
within the ch~pter. If any of points these are not clear. refer to th e numbered sedio n within the chapte r for review.
47.4 Pharmacotherapy of osteoporosis includes bisphosphonates, estrogen mo dulato r drugs, and c;alcitonin.
47.5 For osk'OO rthrltl s. th e main drug thernp)' Is pain medication that includes aspirin, acetaminophen. NSAlDs, or
stronger analgesics. Drug therapy for rheuJrultoid arthritis includes analgesiC$, anti_inflammatory drugs. glucocortlcolds, alld disease-modifying a11llrheum.1tlc drugs.
47.6 Gout is characterized bya buildupofu r icacld in either the
blood or the joint cavities. Drug therapy includes agents
that inhibit uric acid buildup o r enhance itsexcretion.
The nurse completin g a physical exam on a child diagnosed with osteomalacia would expect to flnd :
l. bowlegs and a " igeon breast.
2. deformities of the fingen; and toes.
3. shortnessofbrl'ath.
4. the use of CIlltches for walking.
1. Cardiac dysrhythmia,<;
2. Patl8lle
). Bone fradures
4. Increased muscle strength
5. Hunger
1:1
A patient has receivooa prescription for alendronate (Posamu) fo r treatme nt of osteoporosis. The nurse would be
concerned aboUllh ls order If the patient Tt.jXIrted: (Select
all that apply.)
1. she enjoys milk, yogurt, and other d.1 iry products and
tries to COJ\SllIlle some with each meal
2. she is llllable to sit upright for prolonged periods
because of severe back pain
3. she is la<:1ose intolerant and rnrely conSllmesdairy
products.
4. she has had trouble swallowing and has been told she
has uproblems with her esophagus."
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748
u.. ,
n..lnt~rySY'temMldEyeolE ...
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EXPLORE
~l1!la::1lili!!fir'------'
t.I\'f.l.JJmgKl 1s)'OOt" ane stDp !or enloe chapt .. l!!\flew mate r~ and
resources. f'repa.t ftr $UCCe$lI with ad~OII<lI ItCU:x -$tyle practlQ!
QUeliti:Jns. inlln:tive ~s ..:I adMties, web Ii1i<s, animations
and videos, and 1II(Je!
AegISltr yow aX!SS code from tI1e Iron! 01 yow book III
-..yn..silgl!il.com .
DRUGS AT A GLANCE
LEARNING OUTCOMES
{IIXJt 75J
Antibiotia {IIlI}tlS4
DRUGS FOR DERMATITIS (IlJIItlS9
Tapial Corticosteroids pot}t 1(1)
DRUGS FOR PSORIASIS ptIItlfJ)
Tapial Cortiwsteroids pogt 161
S)'5temi(Agents ptJlJtl'61
1. Identify the structure and functions of the skin layers and ilS$OClated
structures.
2. Explain the process by which superfid al skin cells are repla ced.
3. Describe drug therapies for skin Infections, mite and li ce Infestations,
acne vulgaris, rosacea, dermatitis, and psoriasis.
4. Describe the prevention and management of minor burns.
S . Describe the nurse's role in the pharmacologic management of skin
disorders.
6. Foreach of the dass~ listed In Drugs at a Glance,know representative
drugs, and explain the mechanisms of drug action, prlm~ry ""tlons, ~nd
import~nt ~dverse effects.
7. Use the nursing process to care Jar patients who li fe receiving drug
ther~py for skin di50rders.
...
SlIlbbb fJI1I1IJ6J
local AnestMtics ptJtlO
KEY TERMS
minoid pogtl56
trytMlN pilI}/'l'lJ
kfratolytic ~756
nits pq 75J
pfdirulicidf,s pi1Jt 751
pruritlK JIII1I7'lJ
psoralen pi1Jt 76J
psor~is JIII1I76D
IIfIKW
ac:nnulglris pqllS
romfdone pa)f 156
d!ormat~il
Knrnl
PIl!/t7S9
,..1S9
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rosKfa
{A1It m
~ (Xl9tlSJ
~bonhN {!09f 755
(llJlltl5C
750
olthe Skin
To understand the actions of dermatologic drugs, it is necessary to have a thorough knowledge of skin structure. The
skin wmprises three primary layers: the epidermis, dermis,
and subcutaneous layer. Each layer of skin is distinct in fom}
and fimction and provides the basis for how drugs are injected or topically applied.
EPIDERMIS The epidermis is the visible, outermost layer
that wnstitutes about 5% of the skin depth. The epidermis
has either four or five sublayers depending on its thickness.
The five layers from the innermost to outermost are
stratum basale {also referred to as the stratum germinativum).stratum spinolUm, stratmn granulo5um, stratum lucidum, and the strongest layer, the UTatwlI corneum. The
stratum corneum contains an abundance of the protein
keratin, which forms an effective barrier that repels bacteri.1 and foreign matter: Most substances cannot penetrate
this barrier.
The deepest epidermal sublarer, the stratum basa.le, supplies the epidermis with new cells after older superficial cells
have been damaged or lost through normal wear. Over time,
these newly created cells migrate from the stratum basa.le to
the outermost layers of the skin. As these ceUs are pushed to
the surface they are flattened and covered with a water-insol uble material, forming a protective 6""1. On awrage, it takes a
cell about 3 weeks to move from the stratum basale to the
body surface. Specialized cells within the deeper larers of the
epidermis, called melanocyres, secrete the dark pigment
melanin, which offers a degree of protection front the SWl'S ultraviolet rays. The nwnber and type o f melanocytes determine the overall pigment of the skin. The more melanin, the
darkfr the skin color.
"'"
Infectious
DERMIS
Beneath the dermis is the sub cutaneous layer, or hypodermis, consisting mainly of adi-
SUBCUTANEOUS TISSUE
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Example5
Saamal infenions:boiI~ inptliljC\and ilftclf<i hili
folidts
~ltic:
size, types, and character of surface lesions may have systemic causes such as liver or renal impairment, cardiovascular insufficiency, mE1astatic twnors, recent inj u ry, and
poor nutritional status. The relationship between the integumentary system and other body systems is illustrnted
in ". Figure 48.1.
The pharmacotherupy of skin disorders mar be conducted with oral or topical drugs. In general, topical drugs
are preferred because this route delivers the medication directly to the site of pathology and systemic adverse effects
are rare. If the skin condition involves de.."er skin layers or
i< exteIwve, oral or parenteral drug therapy mar be indicated. Some conditions such as lice infestation or sunburn
with minor irritation warrant only short-term phannacotherapy. Pro longed and extensive thernpy i< sometimes
required of eczema, dermatitis, and psoriasis.
Endocrine syatem
Hotmones influence
glandula. activity, calcium
homeostasie, and skin h.... llh.
PHARMFACTS
Skin Disorders
An estimated 3 million ptOpIe with ntW me oIlic:t infestation art
tll'itfd t<Kh ~ir in tIN> Unilfd Statrs.
The integumentary
ay.tem
Nervous syatem
Emoliomo sfteeI skin
coIoralion. The skin is a
sensory organ.
Cardiovascular s yatem
The blood canies oxygen
and carbon dioxide, 1ae\ore
1h&t influance skin health
and ooIotrllion.
Reapinotory syatem
The lungs provide
oxygen 10 all
celie
in the body.
Lymphltic syatem
Helps fight disea .... s and
inteclions 01 the &kin.
S keletal syatem
II. stora.ge site
Ier calcium. an important
"';""ral connecle<l w;th
vita"';n 0 lundion.
Digestive aystem
Prope. nut,~"", is imporlan\
Reproductivs ay.tsm
Urine. y s y.tem
The ao:um.Jlation 01 Io>cic
54.bslar>c:ola in the
". Flgure48.1 Interrelallomhlps of the Integumentary system with other body systems
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75 1
health.
752
SKIN INFECTIONS
The skin is normally populated with microorganisms or
flora that include a diverse collection of viru.ses, fungi, and
bacteria. A5 lo ng as th e skin remains huhhyand intact, it
provides an effective barrier against infection from these or_
ganisms. The ski n is very dry, and keratin is a poor mergy
source for m icrobes. Although perspintion often provides a
wet environment, its high salt conU'nt disoourage:s microbial growth. Furthermore. the outu layu is continually being sloughed off, and the microorganisms leave with the
dead skin.
SKIN PARASITES
Common skin parasites include mites and lice. Scabies is an
eruption of the skin caused by the female mile, SnrroplN
scabiei, which burrows into the skin to layeggs that hatch af_
ter about 5 days. &abies mites are barely visible without
magnification and are smaller than lice. Scabies lesions most
commonly occur between the fingers, on the extremities, in
axillary and gluteal folds, around the trunk, and in the pubic area, as shown in Figure 48.2. The major symptom is
intense itching; VigOroWi scratching may lead to 5eCondary
inf..ctions. Scam... i. readily sprl1lld through cont~ with
upholstery and shared bed and bath linens.
Lice are larger than mites, measuring from I to 4 mm in
length. They au readily spread by infected clothing or close
Bacitracin ointment
Erythromycin ointment (Erydtrrn, others)
Gentamicin cream and ointment
Melroniduole cream ~nd lotion
Mupirocin (Bactroban )
Neomycin with po lymyxin B (Neosporin), cream and
ointment
T~tr~<.ydi,,~
arc
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ClIopl .. 4I Drug'/OfSklnDIsom...,
753
48.4 Pharmacotherapy
with Scabicides and Pediculicides
Flgure48.J
Pediculuscapilis
Scabicides are drugs that kill mites, and prdirulicides are drugs
that kill lice. Some drugs are effecth-e against both types of
parasites. The choice of drug depends on where the infestation is located, as well as factors such as age, pregnancy, or
breast-feeding.
The preferred drug for lice infest~tjon is permethrin, a
chemical derived from chrysanthemum flowers and formulated as a 1% liquid (Nix). This drug is considered the safest
agent, especially for infants and children. Pyrethrin (RID,
others) is a related product also obtained from the chrysanthemum plant. Permethrin and pyrethriru:, which are also
widely used as insecticides on crops and livestock, kill lice
and their eggs on contact. These agentsareeffecti~ in about
90% to 99% of patients, although a repeat application may
be needed. Side effects are generally minor and include
stinging, itching, or tingling. Malathion (Ovide) is an alternative for resistant organisms.
Permethrin is also a preferred drug for scabies. The 5%
permethrin cream (Elimite) is applied to the entire skin surface and allowed to remain for 8 to 14 hours before bathing.
A single application cures 95% of the patients, although
itching may continue for several weeks as the dead mites are
remo~d from the skin. Crotamiton (Eurax) is an alternati\'e
scabicide available by prescription as a 10% cream.
PHARMACOKINETICS
Onset: 10 min
Pt-ak:Unkl"lown
Half-life:Unknown
Ouration:3h
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ADVERSE EFFECTS
I'Mntthrin uws few systemic: rlftm. Lotalll'<lctioos may oc:rur and induoX
pruritus, rash, transil'm tingling..buming,lIinging.. rrythema,and tdema of the
alfecttd all'a.
Contraindi (<ltions: Contr<lindiutions iIKludt hyprrll'nsitivity to p)'II'thrins,
chrysanthtmurm, IUlfites, or othtr plI'SfrntiYH. Pt lll"ll'thrin !hoold lit uSfd
(iutious~ over inflamtd !kin, in tOOIl' with uthma, Of in I<Ictating womm.
INTERACTIONS
Dru;rDIII!I: No dnKaly s9Wfunt 'lfrac:tionI 11m bft'O do<umtored.
li bTesll:Uoinown
Herb<lVFood: Unknown
754
Assessment
Siseli.e assessme.t prior to administration:
Undmtand the rmon the drug hn been pr~ribed in order to iS~ lor
therapeutic tfftns (t .g. specific t)'JIt ofinftstation such as licd.
Illtain. complt!t health history includingdennato!oqicandsocial history
01 rKfIIt tlj)ORJrI'.
Illt.in a drug histOfY including aUt"1ie,currtnt prescription and OTe drugs,
herbal preparations, akohol use, and smoking.Be alert to possible drug
interactions.
Assm wn artas to be truttd for signs 01 inftstation (t.g., lict or nits in
hai~ ~ed
artas hetw~ wtbs 01 fingtB,around belt or elastic
fines), irritation. enoriation, or driinage.
Illtainbaselineheight, weight,u.d vital sign~
tnc.
Implementation
Interventions and (Rationales)
hSiring thfnptutk effects:
Monitor appropriatt medication adminillrlltioo for ojltimum I'tSlIl1S.
Monitor the .ffected area .after treiltment DYtr the following 1to 2wNI;s to
ensure the infestation has been eiiminattd.{Appropriateidminillrationwill
optimizt. theraPfutic: efftc15 and limit need for retreatment)
Minimizing .dftfSe effects:
Monitor lhe arl" ofinftstation over the nut 1to 2 weeks.ReinftStatioflS
may appear within 1wetk and need to be retreated ilt th~t timr.(Most
trl'atments aft' highly efftie when administered correctly. Retlt'atmmt
rMj be nfflled dtPfndel1t on the type of inftstation.)
Monitor family membm, those in dost (arl' of patient, or sexual (ontaro for
inftStation. Bedding and pefson.J1ob;t<ts shotJld be de.1nstd heforl' 1Mt.
{Reinftst<ltion may reoJf if those in dost contact wi th the patient art
inftSted (lose contam should be tseattd at the Silme time as the patient.)
Monitor s~n in arl'u that have been tsnttd.Promptly report any irritation,
broken skin,erythema, ras hts, or edema. (Skin It'actions ,rt rtlitivtly
uncommon but may occucAllergK reactions should be reported promptly.)
Patient Llndtrnanding of drug therapy:
Use opportunities during administration of medications .nd during
ilSsessments to discuss tile ratioNIt for drug therapy, cltsired therapeutic
outcomes, rommon advtlSl! effects, parameters for whm to (.Illlhe health
C'rI' providtt and irrj nec:essary monitoring or plt(.llJtion~ (Using time
d.Jfing I'A.lning cart helps to optim~ and reinfortf Ry teaching arn~)
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Instruct tile patient. family, or caregiver to (ootinue to asstSS tht illN daily
for 1to 2 ~ and cootact the htalth (.IrI' prtwider for a SKOnd
prtsoiption if rrinfestation is nott<!.
Instruct the patient, family, or caregiver to wash btdding,dothing IIStd
CUrrtfltly, ilnd combs ilnd brushes in ~py wattr and dry thoroughly.
Va<Wm fumituft' or fabric that <annot be dnned to rtlflOYt any tmnt
Yfnnin. Dry dNn hats or (.Ips that cannot he washed Stal children's toys
inpiasticbags for 2wteksiftheyunnot bewashed.
Ttach the patienl,family,orcarl'giverto report any rtdne5s,swelli~
itching. or e)l(oriation, oril complilints of burning CUt to the htalth Uri'
provider.
The patient should be ,ble to stilte tilt reilson for tilt drug,appropriatt
dose and (MWli~ and what advelst tffects to obstrn for and when to
rtpOrttiltm.
ClIopl .. 4I
75 5
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48.S Pharmacotherapy
of Acne and Rosacea
Medications used for acne and related disorders are avail
able OTe and by prescription. Because of their increased
toxicity, prescription agents are reserved for more sevue,
persistent cases. These drugs are listed in Table 48.2.
ACNE VU LGARIS Arnnulgaris is a common disorder of the hair
and sebaceous glands that affects up to 80% of adolescents.
Although acne occurs most often in teenagers, it is not Wlusual to find patients with acne who are older than 30 years,
a condition referred to as mature acne or acrle tardiw. Acne
vulgaris is more common in men but tends to persist longer
in women.
Although the precise cause of acne is unknown, several
factors associated with acne vulgaris include abnormal
formation of keratin that blocks oil glands and seborrhea,
the overproduction of sebum by oil glands. The bacterium
Propionibacterium awes grows within oil gland openings
and changes sebum to an acidic and irritating sub.tance.
756
Rl!!T1arks
idaJlalelll'lootmo)
Rtlinoid-ik~
Fm~d to lIICIdtfit~
Combination product with.lO oIntibiotitand j retiloid in 01 gel ba!t;for mild 10 rnOOeralt oIUlI'
Oral (ontroKtptive ir~ !OIII~~ lI!ed for oKJlI';wmp\t:~il1'!l etratiol pkII norgtIIimat~ (Onllo TrHydtn28)
iIotretiooio (AaUtiIll'J
F !f'Im' oKJlI' with 'Ysn or lItnt forTntd in Ynall, IOIIIdtd rna\.Se; prtgnaocy <at~ X
F !l'n~tM skin; somd~s (ombined with 5UI1l' 10 promot~ pl'd llg, ~ in t~ tonditioo roSoKN; illO U!I'd lor
(onjllotti'litil
tmrotrlll' (T.uor.Kj
Areliloid ttug that may allO tit UItd lor plaq~ pIOIiaIis; MI antiprdi/eritiv~ and aotHnftammatory ~fffflS
tetraqdioes
O trrtinoin (R~o-""o1hm)
To prt'Imt dog4jing 01 porr loIlidts; allO u!I'd for t~ ummmt 01 aM\' promytlotytit IetJkemii ind wrio~
the skin. Other factors associated with acne include androgens, which stimulate the sebaceous glands to produce
more sebum. This is clearly evident in teenage boys and in
patients who are administered testosterone.
Acne lesions include open and closed comedones. Blackheads,oropen romedonn.occurwhen sebwn has plugged the
oil gland, causing it to become black because of the presence
of melanin granules. \Vhitehcads, or closed comedones, de velop just beneath the surfa'e of the skin and appear white
ratherthan black. Some closed comedones may rupture, resulting in papules, inflammatory pustules, and cysts. Mild
papules and cysts drain on their own without treatment.
Deeper lesions can cause scarring of the skin. Acne is graded
as mild, moderate, or severe, depending on the number and
type oflesions present.
The goal of acne therapy is to treat existing lesions and to
prevent or lessen the severity offuture recurrences. The regimen used depends on the extent and severity of the acne.
Mechanisms of action of antiacne medications include the
following:
Inhibit sebaceous gland overactivity
Reduce bacterial colonization
Prevent follicles from becoming plugged with keratin
Reduce inflammation of lesions
Benzoyl peroxide (Benzalin, Triaz, others) is the most
common topical OTC medication for acne. Benzoyl peroxide has a kmtolytit effect, which helps dry out and shed the
outer layer of epidermis. In addition, this drug suppresses
sebum production and exhibits antibacterial effects
against P. acnes. Benzoyl peroxide is available as a topical
lotion, cream, or gel in various percent concentrations.
Typically, the patient applies benzoyl peroxide once daily
and in many instances, this is the only treatment needed.
The drug is very safe, with local redness, irritation, and
drying being the most common side effects. Other kera-
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tolytic agents used for severe acne indude resorcinol, salicylic acid, and sulfur.
Retinoidsarea class of drugdosely related to vitamin A that
are used in the treatment of inflammatory skin conditions,
dermatologic malignancies, and acne. The topical formula tions are often drugs of choice for patients with mild to
moderate acne, particularly those with the presence of inflammatory cysts. Tretinoin (Retin-A) is an older drug with
an irritant action that decreases corned one formation and
increases extrusion of comedones from the skin. Tretinoin
also has the ability to improve photodamaged skin and is
used for wrinkle removal. Other retinoids indude
isotretinoin (Accutane), an oral vitamin A metabolite medication th.1l aids in reducing the size of sebaceous glands,
thereby decreasing oil production and the occurrence of
dogged pores. Although extremely effective, isotretinoin is
rarely used due to the potential for birth defects (pregnancy
category X) and the fact it has been associa ted with a risk of
suicidal ideation. Therapy with retinoids may require 8 to
12 weeks to achieve maximum effectiveness. Common reactions to retinoids include burning, stinging, and sensitivity
to slllllight. Adapalene (Differin) is a third-generation
retinoid that causes less imitation than the older agents. Ad ditional retinoid-like agents and related compOlmds used to
treat acne are listed in Table 48. 2.
Antibiotics are sometimes used in combination with acne
medications to lessen the sevt're redness and inflammation
associated with the disorder, especially when the acne is inflammatory and results in cysts and pustules. Doxycycline
(Vibramycin, others), minocydine, and tetracycline, ad ministered in small doses over a long period, have been the
traditional antibiotics used in acne therapy. Erythromycin
and clindamycin are frequently used topically and have a
low incidence of adverse effects.
Oral contraceptives containing ethinyl estradiol and
norgestimate may be used to help dear the skin of acne.
The agents are reserved for women who are unable to
take oral antibiotics or when antibiotic therapy has
757
Avoid adminimring ore II!' medication! and using sl::in produm that
WIII' I'J{l1si"l'!' drying of the skin during therapy.
kroid dill'ct rxPllUll' 10 sunlight or UV lamps.
Do oot administerto p-atienG whoall' alier9ic to rlSh (th~ product contains
rlSh protti ns).
Pll'9nanry Ulfgory (
ADVERSE EFFECTS
N.~rIy All p-atienu using "'pical twinoin will ",.;...... re:I~. =Iing. ery.
thema, CMting, and pffiing of the Ikin. Skin irritation ran be II'Yl'Il' aM Will'
diKontinuation of therapy; aM ' stll'nqth solution miy bt n~cl'llolry. Otrmatologic adYersr elle.:ull'solvt ooce th~rapy ~ dil(ootinue<i. D"ltooapy un
also(ius~ \kin olIIYenerifms.
VrfY high or~1 doll'! u n Il'SIlIt in ~ adY!'M efle(\~ including OOIlt
p-ain, '""', headoKhe, naus~a, yom iting, ra 5h, stomatitis, pruritu ~ I'Mating, aM
orular disorders. The oral drug has ~"l black 00. warnings, inckJding the p0tential for rapid d.-;~Iopm~m of k-ukorytosiland the polIsibility of S~1l' reactions in ~titnts with promyelocytic leukemia.
Contraindicdions: Com"irKiutioos for tapinl admin~tratioo iKUIe rmma,
elpolUll' 10 sunlight or IN raY', sunburn, hypmrn ~tMty to the drug or vitam in
Apreparation, and children !tss than 12 )'u rs of age. This drug is comr~indiratN
duringlaaation or prt'9nancy. Oral minoin is cont"iMinied in p-atienB who
haYe hepatic disem, !tukoptnia or neutroptnia,or who a~ hypl'Mnsit~ to
the drug.
INTERACTIONS
Dru;rDrug: T~ arnt kfr.Itinolytio~, rflOlCoo,bfnzO)"I pl'IOlide. and
sak)1ir iddl may incll'R inllammation and PfMng;lopnl tro1KB (OOtainiog
PHARMACOKINETICS
On~t: Unkoo'Ml
Pf,ak:Hh
Ll bTl5ts:NOOftmwn
Duration:Uoknown
HI'IiIiI VFood: ED:~~'II' all"llUllB of vitamin Aor Sl. John\ '/IOCIIM)' II'IUk in
ftuoroqu~orsWfonam~
pho\oII'nIiI:ivily.
Treatmf nt of ()mdo~: D-muse of the topical drug will lead to eJ(tlsiY!' sl::in
drying and ~ing. Symptoms of oral OtrdOl~ all' oornptrifk and resol"l'!' with
symptomatic treatrroent
IItftrlO M)MmllrgmfrlfQNlmlnl} I'nxm foaTispKlk lOrlrlsdrui}.
proved ineffeclive. For Ihe actions and contra indications of oral contraceptives, see chapter 4500 .
ROSACEA Rosa(fil is an inflammatory skin disorder of unknown etiology with lesions affecting mainly the fa ce. Unlike acne, which most commonly afffCts teena gers, rosacea
is a progressive disorder with an onset between 30 and 50
years of age. Rosacea is characterized by small papules or
inflammatory b umps without pus that swell, thicken , and
become painful, a hown in ... rigure 48.4. The face take.
on a reddened or flushed appearance, particularly arolUld
the nose and cheek area. \Vith time, thf redness becomes
more permanent, and lesions resembling acne appear. The
soft tissues of the nose may thicken, giving the nose a red dened, bullous, irregular swelling called rhinophyma.
Rosacea is exacerbated by factors such as sWllight, stress,
increased temperature, and agents that dilate facial blood
vessels includin g alcohol, spicy foods, skin care prod ucts, and
warm beverages. It affects more women than men, al though
men more often develop rhinophyma .
The rnu most effe.;:tive treatments for rosacea are topical
metronidazole (MetroGel, MetroCream) and azelaic acid
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.. Flgure48.4 Rosacea
Source CourfqatDr. Jaw n L Smlrh.
(Finacea). Benwyl peroxide maybe applied as needed.Alternative medications include topical clindamydn (Qeoon-T,
ClindaMax) and sulfacetamide. Tetracycline amibiotics are
of benefit to rosacea patients with multiple pustules or with
ocular involvement. Severe, resistant cases may respond to
isotretinoin (Accutane).
Assess ment
--+-
ltac:h the paOOJt 10 9tfIIly dtilflSf tilt skin usirlg iI nonoily SOolp and
noidilllJ rigoJOlJllCJUbbin<J.II9(~lMdrynesl O(lJJ\ lilt I nonoily lotion
tUJUsof drynesl..
Instruct tilt patient l.imii)", 01 wtgiYtr II) immf~ml)' rtporI.ny ligns of
~td
- ,_ _f-c'='=
~=(,Jrt provicIK.
Monitor (Be, lipid Itvrh,and hf~ric function Lib! ptriodiu li)"1or pi!itnu on
0Ia! mtdiciItion.{Lipid !Mil may incrt.1f in up to 7(19(, of Piltieflts on OIl!
.(IIt Ibtrapy: Hepatotoxicity is In ~If rfft of orill drugsJ
InstnKt the patienlto mainQin ltCJuLlr~ eums ilnd to I!pOII any daingrs
in l'isual leviI)', tspfciillywitlt night drmog.
Tth the pabtot !!wt artifiOlllNr lOIutiom may iII!&! in !Mring f'ft dQorss.
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(lIoplOl41 Drug,ro<SklnDMrd...,
759
'''.
Matt, patienll mustffnry that thty will UI!' a barrMor melhod of binh
comrol and 001 donate blood whi~ on lilt drug.
--+--
Ihr patitnt should bt able to ,latt tht INion for tht drug.appropriate
doI!'and Ilhtduling.ind what adYl'lIl' tffl'ltS to obSl'l'YI' for 0100 wlltn TO
Il'portthem.
all'a~)
E'f<Iluatt tht tffe.:li~s of drug thtrapy by mnfinning that patiem goalsand aptCled oukomrs haYe betn met (~Planning").
Aloe Vera
Alor mol is deriYl'<i from the gel inside tilt- ~af of tile alor plim, which is a
mrmbtrof tilt lily family.~ I'ffiI romains ~r 70~wbslalKrs,ilKkid
ing amioo iKids, mint-r~1s, vitamins, and enzymrs. ~ wbsialKrs aft'
dilimed to kill a 'f<IrMol)' ofmicroorglnisrm.de{ft'i\!' ~in.and Il'duc:t- localized
inflammition.Alorvm 011,0 has yallll' for ill moisturizing ilnd woond IItlling
proprrtits.1t has ~n used m~dicinally for lhousanm of yrm. Tlltft' art numerous alor prodJru .nrailib~, in{kiding ~ps,lotions, {Il'am~ ind sunbIoc:ks. Theil' ha~ brrn few standardill'd dinicllll'lI'aKh studies rumining
thr rfftaiYenm of ilor vera gel.
DERMATITIS
Dermatitis is genernl term that refers to superficial inflamma tory disorders of the skin. General symptoms include local
redness, pain, and pnuitus. Intense scrntching may lead to
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no:oriat ion, scratches that break the skin surface and fill with
blood or serous fluid to form crusty scales.
760
~tlention
~mOllnt
of glllCOCOT_
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TABLE 48.3
Topical Corticosteroids
Generic Name
TracK> Nam1'5
dOOelald propional~
difioralonuii(~liIt~
HIGH POTENCY
amdoonidlo
ftuodnon~
haldnoriill'
MEDIUM POTENCY
bctamcthasone bcnzo.JI~
~""
bctamcthaOlll' valtr.u~
Val~
doconolone
ill'Wlimtl~,lJNm
""""
ftuodnolOlll' '(tlon~
S)"nalal
Topilon
fturandl!llOiill',aNm
Cordlan
U/lMlt
ItydllXorti!Olll' \\Iltral~
W~(on
~liIOIII'rulOill~
",,00
triamd~ arnon~
Ari5fO(0I~Kmalog
...."
Ado'o', le
.....
DtsooaIl',DeIOwm,
...
Cortizm~ H":OII
PSORIASIS
Psoriasis is a chronic, noninfectious, inflammatory skin disorder that affects 1% to 2% of the population and appears
with greater frequency in people of European ancestry. The
onset of psoriasis is generaUy established by 20 years of age,
although it may occur throughout the life span.
761
TOPICAL THERAPIES
~ Flgure48.5 P'sorlu's
Source: CooneI)' afar. Ja!Of"l L Smirh
Although the etiology of psoriasis is incompletely understood, it appears to have both genetic and autoimmune
components. About 50% of the cases have a genetic basis,
with a close family member also having the disorder. One
theory of causation i.; that psoriasis is an autoimmune condition, because overactive immune cells release cytokines
that increase the production of skin cells. There is also a
strong environmt'ntll component to the disease: factors
such as stress, smoking, alcohol, climate changes, and infections can trigger flare-ups. In addition, certain drugs act as
triggers, including allgiotensin-=nverting .,nLym~ (ACE)
inhibitors, beta-adrenergic blockers, tetracyclines, and nonsteroidal anti-inflammatory drugs ( NSAIOs).
The goal of psoriasis pharmaootherapy is to reduce skin
reddening, plaques, and s.:ales to improve the cosmetic appearance of the patient, leading to more normal lifestyle activities. This is accompfuhed by reducing epidermal cell turnover
and promoting healing ofthe psoriaticle:sions. Choice of therapy depends on the type and extent of the disease, and the history of response to previous psoriasis treatmE"l1t.A nwnberof
TABLE 48 4
Typesof Psoriasis
Form of Psoriasis
OescrlpUon
Comments
(dropliu) or
mtp~ft psori.tsis
UpptrU\JnkatM! utremitie
Guttal~
vul9aris
Psoriasis v!Jgaris
Psoriaric iUlvitis
Psorialic ~rythrodenna or
ufoliiltil'l'rlffinalitis
Pustuir psoriasis
"'"
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"
762
Adv~rSl!
uI~rifllf(Dovol'lu)
Drug
EffI'CIS
TOPICAL MEDICATIONS
!:!r! &iR!IH!!~!lUfffSll
~Ikyljc~ ~IaJc, NMJOgmI,OIhm)
UliKlit'1H' (Tazorac)
[~pr!Jritr4llingingM"" skin
IIowi!M~~!!m!
tie &i2VSMfottnrrffrQ!
SYSTEMIC MEDICATIONS
acitrtlil (SoriaUnt)
IfIXri()/)lllNdQdtt fDih
Miljg~!IdtI
altfactpl (Arnt'iM)
Il:IiII!D ~!iIlDI
bW!O\9Xkttv Iympboptnia
qdolpCllilH' (SindimmulH', Nrorall (w
pag!' m for Ille Protorypt DruIJ box OO)
tlalH'~ (&lbrrI)
......
t~~Ig/DJ,Wdomill<lpoi~ I(IIIIjrifl9,
Ink!!!!!!l~ par" ,IOD<:lii M~I!!:Il!lfjilll!!:
ilfliJirnab (Rmlicadt)
I/aJh,mioor nfriam
Infi!!l!t!l::tt~!!:!1 BUI!m1;
gg 11lIf:ai2l!r
umkinumab (Slmra)
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SYSTEMICTHERAPIE"S_ _ __
5011ll,' patients have severe psor~si5 ~t is rd istlntto lopical therapy. BKau.se the5e drugs have the potent~llo cause
more serious advSe dfecu, they are generally only U5td
when topical drugs and pholotherapy (ail 10 produce an adequate rdponse. ln $Orne cases, systemic drugs may be used
for a few weeks 10 produce a rap id improvement in symptoms before beginning topicalthl-rapy.
The most often prescribed systemic drug for severe psoriasis is me thotrexate. Methotrexate (Rheumatrex. TrelGlll ) is
used for a variety of disorders, including camr)()lnas and
rheumatoid arth ritis. inaddition to bei ng used for the treatment of psoriasis. Methotrexate is presented as a prototy~
drug in chap ter J700.
Othe r systemic drugs for psoriasis include acitre tin (5oriatallt), which is taken orally 10 inhibit excessive skin ceO
growth. Cydosporine (Sandimmune. NeoraJ). an immunosuppressi\'l! agen t. may be used for severe condi ti ons. The
newest psoriasis therapies include biologic agenlJ such as
a1efacept (Amevive). adalimumab (H llmira). usttkinumab
(Stelara ). etanmept (Enbrel), and inflillimab (Remic ade).
These drugs :act by suppressing specific aspects of the inDammatoryand immu ne responr.e:s.Several of these arealso
used to tr~t rheumatoid arthritis (chap ter 4700). A major
disadvantage of these biologic drugs is that theyare very expensive and not availab le in oral formulations.
NONPHARMACOlOGICTHERAPIES
Phototherapy with u.ltrrnolet-A (UVA) and u.lturiolet-B
(WB) light is used in cases of seven" debilitating psoriasis.
Phototherapy wi th UVA is combined with me~len, a
d rug from a che mical family known as the psor.Jem. The co ncurrent use of UVA and the drug is called PUVA therapy.
Psoralensareoul or topical agents that produce a photosensitive reaction when exposed 10 UV light. This reaction reduces the n umber of lesions, but un pleasant side effocts
such as headame, nJusea, and skin sensi tivity still occur,
limiting the effectiveness of this therapy.
UVB therapy is 1es5 hazardollS than UVA therapy. The
w~vdength of UVB usimilar 10 sunlight. and it reduces le5ions covering a laflll' area of body tha t normally resist topica l tr~tments. With dose su ~rvision, this type of
phototherapy can be administered at home. Keratolytic
pastes art often applied betwetn treaunenlS.
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Chapter REVI EW
KEY CONCEPTS
The numbered key concepts provide
succinct summary of the important points from the corresponding numbered $!"Clion
within the chapter. If any of these points are no! clear, refer 10 the numbered section within t he chapler for review.
48.1 Three layers of skin, epidermis, dermis, and 5utxutaneous
layer, provide effective barrier defenses for the body.
48.2 Skin disorders that may benefit from pharmacotherapy
4&., The most effective treatment fordermatltis Is topia] gJucocortiooids, wh ich are claSSified by their potency.
The patient is treated for head tire with permethrin (Aetleln, Ellmite, Nix). following treatment. the nurse rei nfolU'S instmclions to:
I . remain isolated for48 hours.
2. lnspea the h:tir shaft, checking for nltsdaUy for 1 ",10:
following treatment.
J. shampoo with permethrin three times perday.
4. w.Jsh linens with cold w~ter and bleach.
Careful atten tion to directions for application of permethrine (ActJdn, lImite, Nix) Is emphasized by the nurse.
Signs of inapproprhte over-~ppUcatJon include; (Select
aU that apply.)
\. nausea and vomiting.
2. headache.
J. ~ irritation.
4. diaphoresis.
5. resde:ssness.
The nurse evaluates the patient's understanding of the
procedure for application of triamcinolone (Kena\og,
Aristocort ) cream for acute contact dermatitis of the
neck, sewndary to a reaction to perfume. The patient a5ks
why she ~can't jus! use up some f1uocinonide ( Udex)
cream she has left owr from a poison ivy dermatitis last
month.nlbe nurse's response will be based on the knowl edge that:
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<by.
3. use oil-free SUJlS(:reE'DS, sun hats, and protective clothing
to avoid sun exposure.
4. expect some dryness, redness, and periing while on the
drug but R'port st'\'ere skin irritation.
ClIopl .. 4I
II
765
s.:reenings at a public health clinic. While examining a 4month-old infant, the student notes an extensive, conflu ent diaper rash. The baby's mother is upset and asks the
student nurse about the use of OTC corticosteroid ointment and wonders how she should a pply the creanl. How
should the student nurse respond!
~-~'----,
EXPLORE
M~rs"'~l'.it II )'0<1' "" . <fOp lor onti .... erlal>\Of .. "' .... ",. lor1. lS.rIC!
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DRUGS AT A GLANCE
LEARNING OUTCOMES
knaooprost (Xa/aran)
AutonomicDrugs /it169
Q
{IJ9t m
""m
pressure.
S. Describe the nurse's role In the pharmacologk management of eye and
ear disorders.
6. Identify drugs for treating glaucoma and explain their basic actions and
adverse effects.
7. Identify drugs that dbte or constrict pupils, rela. ciliary muscles,
constnet ocular blood v~~s,or moiste n eye membran~.
8. Identify drugs for treating ear conditions.
9. Use the ......sing process to Gart for patients vdlo are receiving drug
therapy for eye and ear disorders.
KEY TERMS
Iqueoushumor p<1Jt761
doSfd.angle glalKOITIII fJ09f loa
cydoplegkdrug1 pqjtJ74
melTWlotiris I#ItllS
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gluromil
pai/tl6iJ
l1altoidit~ pu;t176
l1ios~ ptl/fll'J
l1ydrias~ pu;t ll'J
mydriaticdrugs fJI1Jfll4
optn-anglt glatKoma ",.l~
otit~ media (#It l7S
Ante,io,
and ....in
dlambe ,
Co,nea
Ed~ot
~~
pUp'1
......
'"
Visual
Post..,;."
~.
,. ~
I,;,
Conjunctiva
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,-
&m_
Bony orbit
768
c.~
Slowly Ming
intraocular
press ure
Anterior
,-
Flow 01 aq"'"ous
Notmll a/\Iorior
ct.amber angle
Posterior
chan-ber
,.j
Rapidly
rieing
intraocular
preseure
Canal 01
~---"""
ClD&8d anterior
mmmb", anglo
Trabecular
meshwork and canal
;~;~;'aN~ J '~
(b)
"
~ Flgure4g.2 Forms of primary adultglaucoma:(a) In chronic
open..angle glaucoma, the anterior chamber angle remains
open, but drainage of aqueous humor through the canal of
Schlemm Is Impalred;(b) In acute closed-angle glaucoma, the
angle of the Iris and anterior chamber narrows,obstructlng the
outflow of aqueous humor
GLAUCOMA
Glauroma is an eye disease caused by damage to the optic
nerve that results in a gradual loss of vision, possibly advancing to blindness. This disorder is usually accompanied
by increased intraocular pressure (lOP). Glaucoma mayoccur so gradually that patients do not seek medical intervention Wltil late in the disease process.
"t
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PROSTAGLANDINS
PHARMFACTS
Glaucoma
.....
"'W
"""'-
it remairuopen.lf discovered ea rly, most patients wi th openangle glaucoma can be succtsSfuUytreated with medications.
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769
Autonomic Drugs
Several structures within the eye receive signals from the
sympathetic and parasympathet ic divisions of the 3utonomic nervous system. As suc h,a significant number of au_
tonomicagents have been used to trea t glaucoma and to aid
in ophthalmic examinations of the eye.
BETA-ADRENERGIC BLOCKERS Before the disoovery of {he
prostaglandin analog.'!, beta-adrenergic blockers were drugs
of choice for open-angle glaucom a. These d rugs act by decreasing the prodoction of aqueous hu mor by the ciliary
body, and can lower lOP by 20% to 30%. Beta-adrenergic
blockers generally produ ce fewe r ocular adverse effocts than
other autonomic drugs. In most pa tients, the topiCllJ administ ration of beta blockers does not result in significan t Sy-\lemic absorption.. Should absorption occur, however,
systemic adverse effects may include bronchoconstriclion,
dysrhythmias, and hypotension. Because of the potential for
systemic effts, these drugs should be used with cauti on in
patients with asthma or heart failure.
AlP~A. _ADR~N~RGIC
770
UnII'
TABLE 49.1
Drug
Adwrse Effects
PROSTAGLANDIN ANALOGS
bimatopmt (lIIIligan)
Q)
litanop""1 (XIliun)
tral'(ljlfOll(T!a\'llan)
M~ lfIIS4rionoffoflliQII ~ in rhtfl'!
betaxolol (BtI~ic:)
ItIWunoIoI (Brogan)
mtlipranolol (OptiPranolol)
Q
ALPHA,.AORENERGIC AGONISTS
apradonidiM (lDpidilll')
brimonidilll'lAlph'gan)
" Ii
",_.
a(eQzoLimidt(Diamoxj
brinrolamidt (Azopt)
dorzoLimidt (T!IIIOpI)
md harolamidt (NepI.WIt)
1M
CHOLINERG IC AGONISTS
Glrbidlol (Mioltatj
M:lthiophit~
iodidt (Phospholin~
lodidt)
...(U\~ ~lKom.J:
"IOm~i!IQ
3-1i OOstS
OSMOTIC DIURETICS
iIosoJbidt (kmotic}
mam~oI (O!m~roI)
and produce miosis, constriction of thi' pupil, and contraction of the ciliary muscle. These actions physically pull open
the trabecular meshwork to allow gri'ati'r outflow of aqueous humor and a lowering of lOP. The cholini'rgic agonists
are applied topically to the eye. Pilocarpine (IsoptoCarpine, Pilopine) is the most commonly prescribed
cholinergic agonist. Mversi' effects include headache, induced myopia, and decreased vision in low light. Because of
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their greati'r toxicity and more frequent dosing requirements, cholinergic agonists are normally used only in patients with open-angle glaucoma who do not respond to
other agents.
NONSELECTIVE SYMPATHOMI METICS Nonselective sympatho-
mimetics activati' thi' sympathetic nervous system to produce mydriasis (pupil dilation ), which increases the outflow of
771
I Latanoprost (Xalatan)
ADVERSE EFFECTS
AdYerst tfFeru indudt orul.r symptoms wc:h <IS con;.JIIctiYal tdt rna, tearing,
drynffi, burning, pain, inila!ion, iuhing, ~nsation of Ioft'ign body in ~ pliotophobg, andlor visuil disturNmf5. TIlt l)'tlashes on tht trtaltd fYf may
grow th~ and da~r. Changrs may O((llr in pigmtnUtion of tilt iris of tilt
tft'attd ~ ,nd in tht ptriocular \kin.
Contraindication!: Contraindiutions ilKkide hype~nsitivity to tilt drug or
aoothtr rompolll'nt in tilt solution, pll'gnanq, i.Ktllion, intraocular infection,
or ((Injunctivitis.1t shoold not be administerfd to patitnlS with dostd-anglt
glalKorna.
INTERACTIONS
Dnq-Drug: Lmnop-OII inlfroKU with tilt P-Nf"Iati'll' thirnProla~ II UIfd
(ooumn!ly with 0IIti e)'f.tops (oouiling thilllfllM, PfKipiUtion may Q(OI".
liIb Ti5IS: Unknown
HerlIiJVFood: Unknown
PHAR MACOKINETICS
Onstt3-4 h
~ilk:8-12h
III' ftf I!I M)M!rslrlg/f1l for Q NwI"9 I'n:>:m fOOI5!pf(1k I!I rIr/s ~
Hilflire: 17 min
Duration:Unknown
ADVERSE EFFECTS
Tht mon commonadvr~ tflem art 001 burning and ninging on innillation.
Y"rsion mi~ brromr temporaril)' bUlTI'd In most pnitnts thtre is oot t noogh
ablorptian to UUlor sysll'mic adVt'lSl' rfftm 011 long 011 rimolol is applitd ((IrI'I'ctl)'.11 absorption [l(all!, hypott nsion or dysrhythmgsart possiblt.
Contraindications: Timalol is rontraindicated in patirfm with asthma, Sr'ltll'
chronic obslruct~ pulmona!)' distasr, sinus brad)'Cardi., !e(ond- or thirddtgrtt atrioYl'ntrirular block, hurt lailurt, cardiogeoic !hock,or hyptrsrnsitiYi!)'totlltdrug.
ADMINISTRATION ALERTS
Proprr administration Its~ns thr dangrr that the drug will be absorbrd
SYSlI'micall~. Systrmil: absorption u n mollk symptoms of hypog1yc:tmg.
Pll'gnanquttgoryC
Drug Drug: Drug inlln<tions may 1M" if lignffia,u syu.mi< absorption 01"' .
fmolollhoWd brused with (;1M in ~lItakinllllhfr brIa bIockM ~to
odditWf cardoK fffI>m. (mURalt U\I! with anticho1i1frgicl, niUitrs, rNrpilf,
1MhyIdopa, III wrap.!llil (OUd Iud 10 h)"potmlioo and brad)Uf(ia. pinPJhft
to.
LNTERACTIONS
U\I!(<UdlNdtoh)1lff!Mlionfolowi>dlrf_~ia.
PHARMACOKINETICS
Onstt30 min
Prak: 1- 2 h
Halllilf: Unknown
Duration: 12- 24 h
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liIbTi5Is:Unmown
HerlIiJVFood: Unknown
772
UnII'
Assessment
InstMt the patient of the imponaIKf to ~tum for and maintain regular
InstMt the patient to .Jwid IOIKhing the f)'f drop tip to the conjunctiYal
sac: when instilling f)'f drops.lmmedi~1I'I)o II'pln any iIK~asing ~n.s~
')'f p-a in, r~ drainaljf, or (hJ ngtS in yision.
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')'f.xam~
773
Tt,{h tht j)<ItNont to rttum ta the htalth cart prOYider ptriodically lar
rronitoring. As~1 blood PIffiUR'OllCt ptf week and repln any aoo
bs than 90/60 mmHg or ptr paramtt~rs. ImmNi,J!~1y R'port '11)'
diuines~ headache, palpimion~orlyncope.
a",, ~)
Tmh tht j)<ItNont totakt tilt drug following tilt guidtlillH provided bytht
htalth cart proYider.
St<' TobIt 49. 1(llf ~ Ii5lIf ftu!p re whKh riel lUling ~aiom QPPIy.
aqueous humor, resulting in a lower lOP. Theyare not as effective as the beta-adrenergic blocktors or the prostaglandin
analogs in treating open-angle glaucoma. Epint'phrine is no
longer available for glaucoma. Dipivefrin is converted to epinephrine in the~; thus, its Effects are identical to those of
epinephrine. If t'pint'phrine reaches the systemic circulation, it inneases blood pr~sure and heart ratt'. Be,ause of
tht' pott'ntial for systemic adverst' effects, these are rarely
prescribed for glaucoma.
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than photosensitivity. Oral formulations such as acetazolamide ( Diamox) are very effective at 10wt'Ting lOP, but are
rarely used because they produce more systemic adverse effects than drugs from other classes. Systemic effects include
lethargy, nausea, vomiting, dt'pression, paresthesias, and
drowsiness. Patients must be cautioned when taking these
medications because they ,ontain sulfur and may ,ause an
allergic reaction. Because the oral formulations are diuretics
and can reduce lOP quickly, serwn electrolytes should be
monitored during treatment.
Osmotic Diuretics
Osmotic diuretics are occasionally used preoperatively and
pu,tup"nliivdy wilh u~ular sUfll"r y ur as ~JJlrIl~JJ~y tr~at
ment for acute closed-angle glaucoma attacks. Examples include isosorbide (lsmotic), urea, and mannitol (Osmitrol).
Becaust' they have the ability to quickly reduce plasma volume (cha pter 30 00), these drugs are effective in reducing
the formation of aqueous humor. Adverse effects include
headache, tremors, dizziness, dry mouth, fluid and electrolyte
77 4
EAR CONDITIONS
The ear has two majorseruory functions: hearing and maintenance of equilibriwn and balance. As shown in .. Figure 49.3,
TABLE 49.2 II Drugs for Mydriasis, Cycloplegia, and lubrication of the Eye
Drug
MYDRIATICS: SYMPATHOMIMETICS
phtnMhint (M)'Ifrin,tIeo-S)"n~ntl
III let the Prototype Drug box 00 )
(~paocj~
Adverse Effects
--
!b:1!!!!~nIOO,IIl'~!b:!!I!!!tmial
CYCLDPLEGICS: ANrICHOUNERGICS
~lropilH' (lsoplO Alropil~OIiIt~) (~ pa~ 1
letJlw, Proiotype Drug box OQ )
1 dropofO.5%soIUlion mhday
l- 1drOPlprD
1- 2dropsprn
Vi~nt,olhm)
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t!o!(liou! idl'tl!(dltds
He lix - - - -.,
, - - ,~,.'o, "','." cenels (e quilibrium)
Anlihelix ---~
Ca,lilege ---~C-~-
Concha (bowl)
. .":~~T'~e;;:S~
------~
"",+,;-_" Vestibule
L -'\;__
Lobe ----,~
Tympanic
(.... rdrum)
Internal carotid ar1erv
~
HOME
In modem Amrriun QJku~, oldtr adults ilia)' lift alo~ or with other rldtrty
family 01 friends. Th~ JIr'lplr ofuon ~ to US!' ophthalmic drugs at homr.
As ItSS thrability olthr agirlg ind MdUillto safrly mministrr ophthalmic drugs
in thr homr lfIIing. RWJm drmonstration b)' the patirm lIIiIy bt (ritical br
thr IIJrsr to olIltSsthr oidfl a<kJk's dmeril)' and skill in stH-administrring
~~ mNic,lIions. Hrffied. ~ INsonabir i krmati~ wm as ~p from a
neigh bar, family mrm iII'~ or (')l!giYt r.
T~.Kh ing is critiu Ifor j:OIitiYt OUKOmrs in this POpIJlation. ~ oIdrr adJk
nHCk to uncWrsund th.t lOIKhing 01 rubbing the f'jf un ~k in infedion or
damal}!' to the f'jf. BeraUSf vision may al~idy bt (ompromiSfd, the older
aduk ilia)' rxpffltn~ bkJIIN vision that shoold dear in a lNIonabir timr iftt r using ophthalmic drugs. Caution older i<kJ1ts about trying to drill!' or rim
amoolatl' until this ulKlrar vision improl'!5.Additionilly, with f)'r problrms,
diminishN vision puts thr oIdrr aduk at ilK~astd risk for falls. A~ssthe
homr and IIIiIkt suggrstims 10 improll!' safety. Ca~ should ill' taktn to label
f)'r mrdiutionsto indicatl whic:h is fo, the Itft t)'~ and whic:h is for the right
~r. xht<kJling mrd ic:ations '!!Iund a muti~ SIKh as mr.1s, ako ilia)' hrlp the
oldtr adJk Il'ml'IlIbtr to t.Jkt tht ophthalmi( mrdic.tions as Pll'l(ribed, in(~olIing nKesary rompiianU' fo, hraling.
PNiatric: ~titnts aR' ala tft'atN at homr for ~r disordtrs. Cal!gill!'rs in
thr homr aR' rrsponsiblr :Or administrating and rnsuring thr patiem's (omplialKf with thr drug thrllpy. Thr limr mministration in!lructions apply to
both geriatric: and pedialrK populatiorlS.Caution against IOIKhing and rubbing
thr ~.In the mr of infam, toddlrl\ and Yl'ry young rnildren, it may bt II!'(miry to US!' tlbow splint5 and guards to PR'!'lltthrm from bting ablr to
R'arn thti, ryt1.
Bilbtrry (Voccinium myrtiHlIl), a pint whOl~ lravfS and fruit a~ UIfd m~dic:
ilal)", i; foondin(flltralaoo nonhtm ~Asi.J,and NonhAmtria.lthis btrn
5hown in dilic:al slIKits to iKft'il1t ronj.JfJ:tival (apillary ~tancr in patitnu
with<iabttK II'tinopathy, theft'by pl!l'lidng prottdion agarnt hemonhiI;r 0/ thr
Jttiru.Dnt (ompound in bibto): anthocy.nosicIr, has a ooIlagm.nab~~ing rfffl:lln(ll'astd synthf"lis of (onnmlve tilW!' lilKluding (ollagrn) it O~ of
thr (ontriooting factors that ilia)' Irad to blindne-s5 (aUlfd by tiabttic
'rtino~thy. Silbtrry has also ~n UIfd to rrdu(r rye inliamm,tion .nd im
P""'" night vision. gilb."y m.y braken... tN to liNt nonspKific di.".h...
<tnd Iopiully to trrat inflammation of thr m!KOIJI mrmbrants of themouth
indthlOlll
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tbrH structural areas, the outer ear, middle ear, and inner
ear, carry out these functions. The basic treatment for ear
conditions is topical preparations in the form of ear drops.
z
49.6 Pharmacotherapy
with Otic Preparations
Otitis, or inflammation of thr ear, is a common indication
for pharmacotherapy. [_temal otitis, commonly called
ll'Vimmers ear, is inflammation of the outer ear that is most
often associated with water exposure. OtitismNia, inflammation of the middle ear, is most often associa ted with upper
"
776
AdwlW Effects
fGrirririon.lrxQlllir19ing fI(
blmirrg. diIIintlJ
4ltops irlNrlid-"d
Ala
tuctiom (wibiolja\
and surrounding structures of the middle ear. The treatment of acute mastoiditis involves aggressive antibiotic
therapy. Intravenous gentamkin or ticarcillin may be used
initially; thenlpy may be adjusted once culture and sensitivity results are obtained. Therapy is continued for at least 14
days. If the antibiotics are not effective and syntptoms persist, surgery such as mastoidectomy or meatoplasty may be
indicated.
Cerwnen (ear wax) softeners are also used for proper ear
health. \.\'hen cerumen accumulate.., it narrow~ the urcanal
and may interfere with hearing. This procedure usually in volves instillation of an earwax softener and then a gentle
lavage of the wax-impacted ear with tepid water using an
asepto syringe to gently insert the water. An instrument
called an ear loop may be used to help remove earwax, but
should be used only by health care providers who are skilled
in using it. Examples of earwaJI. softeners include carbamide
peroxide (Debrox) and triethanolamine.
Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding nwnbered section
within the chapter. If any of these points are not clear, refer to the numbered section within the chapter for review.
49.1 Knowledge of basic eye anatomy is fundamental to understanding eye disorders and pharmacotherapy.
49l Glaucoma develops because the flow of aqueous humor in
the anterior eye cavity becomes disrupted, leading to in creased intraocular pres:;ure. The two principal types of
glaucoma are dosed-angle glaucoma and open-angle
glaucoma. Therapy of acute glaucoma may require laser
surgery to correct the underlying pathology.
493 The goal of glaucoma pharmacotherapy is to prevent
damage to the optic nerve by lowering lOP. Combination
therapy may be necessary to achieve this Iloal.
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777
II
The patient is pres.:ribed timolol {Tintoptic} for treatment of glaucoma. The nuTSl' assesses for which of the following medical disorders during the history and physical.
which may be a contraindication to the use of this drug?
(Select aU that apply.)
l. Heart block
2. Congestive heart failure
3. Liver disease
4. COPO
5. Renal disease
1:1
'Y'.
4. leavtngcontact lenses In to be sure the eyedrop Is
maintained in the eye.
~.-----,
M)'NursingM i:I yoor one srlIl for oriine ClHIllIer Itliew materials and
reooolCOlS. I'f~ for success with ad!Jilional tlCLU"-sti\ll IIflIcticlt
que3liDns, In!eractl\Ie Q[lI'IIOOnl'I and aC1l\ii!ies, well tlnks. mtmations
and ~ideos. ;lOO morel
Regllller your a.cce!B roIIe fmm me Iron! 01;001 000k at
www.myn .. U\tkilcClm.
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LibraryPirate
Appendix A
ISMP'S LIST OF HIGHALERT MEDICATIONS
High-alert media.tions are drugs thaI bear a hrightened risk
of causing significant palient harm when they are used in
error. Although mis takes mayor may nol be more common
with these drugs, the consequences of an error are dearly
more devastating to patients. The nurse should use this lis t
to determine which medicatiOI15 require special safeguards
to reduce the risk of errors. This !my intlude stl'1llegies like
improving access to infonmtioo abou t these drugs; limiting
acct'$s to high'alft"1 mIications; using auxiJi:try bbels and
automated alerts; standardizing the ordering, storage,
preparation, and administration orlhesC' products; and employing redwxlancies such as autolruUed or independent
double-checks when necessary. (NOll': manual independent
double-checks 3Tt nOI always the optimal error-reduction
strategy and may not be practical for all of the mediallions
on the list.)
Clanlls/Categories of Medications
adrf-nergic agonislS: IV (e.g., epinephrine, phenylephrine,
norepinephrine)
adrenergic antagonists: IV (e.g . propranolol, metoprolol,
Iabetakll )
anesthetic agents: general, inhaled, and IV (e.g., propofol,
ketamint)
antiarrhythmiQ: IV (e.g., lidocaine, amiodarone)
anti thrombotic agen ts (anticoagulants), including warfa rin,
low.molecular.weight hepari n: IV unfractio nated he
parin, Factor Xa inhibitors (fondaparinux),direct thrombin inhibitors (e.g., arg;lIroban, iepirudin, bivaJirooin),
th rombolytia (e.g., aJ leplase, reteplase, tenectcplase),
and glycoprotein IIbIIIIa inhibitors (e.g., eptifibatide)
cardioplegk w1 utions
chemotherapeutic agents: parenteral and oral
dextrose, hyperlOnk, 20% or greater
dialysis w1utions: peritoneal and hemodial ysis
epidural or intratheal medications
hypogl,,:emia: oral
inotropic medications: IV (e.g., digoxin, mi lrinone)
liposomal forms of drugs (e.g., liposorruJl amphotericin 8)
moderate sedation agents: IV (e.g . midazoLam)
moderate sedation agents: oral. for children (e.g., chloral
hydrate)
narrotialopiates: IV, transdermal, and oral (including liquid concentr.ues, immediate and 5usbined-release formulations)
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"
,.
".
":~
Specific Medications
tpoprostenol (Aolan): IV
insuli n: subcutaneous and IV
magnesium sulfate injection
me thotrexate: oral, nononcologic use
opium tincture
oxytocin: IV
nitroprusside sodium for injection
potassium chloride for injection concentrate
potassium phosphates injection
promethazine: IV
sodium chloride for injection, hypertonic (greater than
0.9% ooncentl1ltion)
sterile waler for injection. inhalation, and irrigation (excluding pour bottles) in containers of 100 mL or more
Background
Based on error Il.'pOrts submilted 10 the USP ISMP Medicatio n Errors Reporting Program, reportsofharmful errors in
the literature, and in put froln practitioners and safety experlS, ISMP created and periodically updates a list of poten
tial high-altrt medications. During ~ebruary-April 2007,
no praclitioners responded to an ISMP survey designed to
identify which medications were m05t freq uently considered high.alert drugs by individuals and organizations. Further, to assure relevance and completeness, the dinical staff
aI ISMP, members of our advisory board, and sa(etyexperts
throughout the United Stales we" asked to review the poItntial li.sl. This list of drugs and drug categories reflects the
collective thinki"8 of all who provided inpul.
, Appendix B
TOP 100 DRUGS RANKED BY NUMBER OF PRESCRIPTIONS
Top 100
Rank Generic Drugs
,...
..,.,.
,.
I.,do
' D. w/APAP
SI.
52.
53.
S4.
55 .
56.
57.
SolI .
litinop<il
.un.......,.
......,....~
.mo:clcill.in
.:cltbromycin
.... ........
hydrocblorothiuido
.Ip......u.m
dinycydine
tlriooprodol
.lIopouin<>l
m<lhy!prl"is<JIon. ..,,,
moloxlc.,.,
omlDdipif>f/bmaupri1
potuIoium cillo,;""
clonidine
59.
prt>m<th.zm.. ..1>0
W.
,I.
62.
63 .
folic tcid
opin>nobctono
&Iimcp'rido
6<1.
pan!<>prU01<
om<pruol.
&5.
~uridt
....pidmJ ",rtnk
o:<ya>dono w/APAP
ibuprohn
prlnioonr oral
".
_"""m~SR
.... ' .... Inobuliuroolution
tridi<!ni,
"-
ft~
n.
~""'"
c:q>hakxin
70.
11.
H.
U.
...
".,.
".
...
H.
".
D.
,..
D.
JDftformin
metoprolol .lKcinato
furo .. mi"'onl
metoprolol tan ....
_ofu.
67.
611 .
69.
.....,...,
_....
b......pril
d..
cJinchmycin .,.mmJc
ramlpri
IMlronidaJOielaN
dulopnm
D.
p bopattin
cipl<>floucin
p~ ... w/APAP
lisiaoprillHCTZ
78.
79.
U.
...
~.
".
".D.
~.
,.
D.
n.
~.
~.
"'.
...
u.
n.
trbmto~CTZ
kmfftladi_
86.
87.
sa.
89.
<Idof""""
grmlibroril
p"'J'rlDOld HQ
vitamia D
quinapril
promed>.>:in</<O<Irino
91.
9<1.
.qd",jr
~.
.mitriptyli_
9';,
m.wzm..
"~
96.
97.
941.
.
fi.
>0.
ft,,,,,,,,,,,,
tnabpri1
<.....dilol
roni. idin.
Syntluoid
Pr~cid
A<lvair !)i,k..
-"
_
.
.
U.
VytOfin
..
Pro-AirHFA
64.
"'.,,",
65.
66.
67.
fulymagma PLaln
6&
Evi
AodoJ:
E/kmrXR
".
"
". ,
,.". "-D.
n.
,.
D.
rno...nHCT
Lcnquin
~
"'"
.""
n.
74.
Vi.J1'
.,...
9'}.
100.
Add.r:oll XR
v"m.
potassium chloride
nllrofutontoin
tulbmcthoumldt,imt1hop,im
f'.1II.nyI ,~01
bwpUoI><
Topamu
,~
,.n.
".
.,
u.
U
."".
,....
n.
N..o",",
Premarin_Tabs
D.
69.
70.
71.
CrIrb...
,." ""'.,
,.n. ,-
u.
pr....... in
.".
AbUlfr
V mln 2&
81>d<prioa XL
Ni."I'""
A.... pro
,_.
. m aminophenJ<Odtin<
lndron'l~
v.
Pmwntil HFA
55.
56.
57.
58.
59.
60.
61.
62.
n
o..nliI
H.
donzooi.
mUtaupi ...
&IipiDde ER
pbentr.mine
90.
91.
92.
.u..,....
Sf.
"".
" "'""
-
",." c"-.,.
8<1 .
85.
trim<thoprimlou\f.r.
!but....! Krosol
Slnguloir
PI ...ix
m ..odop<amXk
h)'d=rz;illf
.mphctamu. WI c:ombinalioa
~roIU.
51.
52.
53.
SJ.
Top 100
Rank Brand Name Drugs
Up;to
N..ium
l1li.
.mo:clcil~nJ davul.n.tt
p.an>n!tine
lon... tin
,.,...
,
,.
.
n.
cydobr=princ
w ..
-.
dipJin
81.
82.
."'""'-
p"aiciD.in VK
""'""""
m<lformin HCl ER
D.
cl""'orpam
'""'uq>Om
.riamcinoiont aC1Ol<>nido. ropial
n.
71 .
7<1.
7S.
76.
,.
Top 100
Top 100
..
Amblm CR
Spiriu
Bonicu
""'m
CombiwDI
la mn';"
Bonin
TriNeosa
Nu.. Ring
Risperoal
Ro\oftlt HFA
[m~,"",onl
~rER
Pmtollix
Avalido
Liodtrm
15.
76.
Z1l'r<:U
N..-nd.
l\usiono::<
n.
78.
79.
80.
81.
82.
83.
84.
Humaloc
Vipmo:<
85.
86.
87.
88.
89.
TomilI:u
Bl>d<prioll SR
Suboooo ....
Lano:lin
Loeotrin 2~ Fo
A...ian
Cownodin ,abo
Wtll>utrin Xl
Endotct
Sbluin
90.
N ..."". AQ
AcipHu
91.
92.
93.
0<
95.
96.
97.
98.
J:q>p ...
Allqro D II hr
SIr OlICl" '
.....
Avandi.
Octl[
Vynnoe
Toprol Xl.
~-.
lamkbl
99.
lrvitno
100.
A"din
BolliclrHCT
Ariorpt
Onho Tri .c,dtn La
..
.",.
Tri-Sprint
a ",
o.,c-m
.
LibraryPirate
,
"-
Appendix C
BIBLIOGRAPHY AND REFERENCES
General R.f.rances
Audcslrk, T.,Audulrk, G~ & Btym. B. E. (2008). BioI"fY: Ufo II"
t.mIJ (Ilih ed.J. San Francisco.Ct.; Bcnjilmln Cummlnp.
Bn, 1.1 . 11., 8r Bcrkow, R. (EdJ. l. (2(l1)6 ). Merck "111111.14' Ditlg/lOSU
AIlII t/wNpy ( 18th m I. WhildlOusc StatIOn, N I: M~n:k!reo.
HoIlmd. N., &: Adams, M. (2007). eon. cvnat'" In pM17fIIIt01of]'
(2nd N .J. Upprr ddk RMr. H I: Prtnlict Hall
Kro&h. D. (2009). ~ Apitk . . . . II<IlItru/ _1d (~lh cd.),
Uppn- s.idk Rlvrr,N,: PrnIoo Hall.
LcMo~, P~ " Burkt, K. M. (2008). Akdir.'IlIJ~" nll";nt=Criliall
rII;t!k.m, III c/imu/JU (.lh N .). Uppc'f Sadd.k RiWt, NI : ~nlkf
1M
Mlrtln~
s.n
Chapter 1
Moort, T. J~ Coht:n, M. R.. r-urbr11o c. D. Q ..... rterWalCh 2008
quantr 2. Rc1rkvN from InMit ... te for s"ff Medication Pr.KIKC1I
wmsile: hnp;l/www.iomp.o.io..QlYrkrWalCh/20090I .pdf
Newton,G. 0 .. Pray, W.s.. &: PopnYk:h. N. G. (2001). Nrw OTC
dr\IP and ckvices 2000: It Kkcti~ mieW. "'~nW oj Iitt Amnirllll
PltanrtQMltiaIJ ~ 41 (2), 273-282.
Na. R. (2004). Dn<~ F..,." cIiscavrq "' 1IJIPI'f1"III. Hnboktn,NI: W'~.
o,.ta, j. A. ( 2006). 1b. Kknof dnl& thenPr. In L L DruolOll,
I. S. ~ Ie K. L PaM (Eds. ), GPordItNlII o-CoJlfII1,(, TM
phil~ k,;, oj.ltuaprutia (11th ed., pp. 117-136). Nno>
'fnrk. NY: M<:GrawHill.
OlKn, D. P. (2000). The p.1lient'1 rt'l)Qnsiblllty for optimum
healthca~. DWllw M~"'1jPI1tlt' cI- fkalrh au,roma, 7(2 ), 57~.
Chapter 2
Bond, c . It. , Raehl, C. L,Ie Fnnb-, T. (2001). Medication won in
United SI<ueshoopitab.. PMrmMVtNrIIp1, 21 (9 ), IOH-I036.
Br-. E. P. (200 I). Oru, therapy: Chan,IIllIM $I<U .... of drup from
prncriplion 10 ()\'ft'IMrounter Inibbility. Ntw EntI.IlflIoIl'tUJJ
of Medirbw..us, 81O-1Hi.
Brown, So 0 .. &: landry, F. I. (20(H ). Ro&nlzin" rtpOrIing. and
mlLICinc IWfwrvdrug roctions. SPllrllrm Itkdool/ /ottmal, 94(.).
370-17J.
Force, M. V.. IXmng. L, H...bbc,}.,ADderten, M .. H.lNnn, 0..
Coopt-r.Hahn, M .. &: ~en, W. (2006). Eff1~ &t .... ~1es 10
Incre_ "'f'OI'llngof medication ffron in ~lall.}oIl'M/ of
N~"'ltg Admilti,"lIrion, J6( I ) 34-41.
LibraryPirate
Chapter]
Armilaat', G~ Ie Kn..plNn, H . (2OOJ). AdYCTK fnn\J In drut
administntion: It liten\\lR miew. Pllntill rtf NIlnilt'
~,,". 11 ( 2), I30-I40.
01
c......
""hI>.
J5-l8.
Chapter 4
Bateman. D. N. (2001 ). Introd ... ction 10 plu.rntacokinclicJ ,nd
p~rmOKOdyn,mlc .. Jowmnl olTwlicology: Qinkal TQ\'irolotr.
JI'(3),207.
Bhlr.tlarml, V. B"Gtild'e, U, Kohlen,C., Vril. M., &: IXrrndorf, H .
(2002). ~Ia and ~bilil y oflxrbl.l mcdkln.ol
produtb. PItyromtdicirw, 9, 1-33.
Brunton. L. L , Luo. j. S~ 8< PaM, K. L (Ed .. ). ( 2006). Goodmatl cIGilman', 1M pftIIr~1tJ IwU oj rhtTnprutia ( lllh ed.). Nrw
'fort, NY: M((i...wHin.
8&aton, l L 0. (2006 ). PhlnlllUlkineti<::sand pharm.cod)'Mmkl:
1b. dyo;lmla of dr ... , IbtollMion, diitribution, ..etlan, and
e~mlllilllion. In L L BrWlton, J. S.1.azo, Ie K. L Puker (Ed .. ),
Good""." cl- Gilmn"j 1JIt PMtm/1ICoJogkal /HuiJ P{lkmlpru,/n
(11th td, pp. I...((). NrwYork, NY: McGnwHiU.
'"
782
AppeoolxC
Chapter 5
ikrg. M. J. (2002. August 31-Septem],.,r 5). Do> H:X ",at",r! Pa",r
p"'s<nted at the Congress oft h~ 62nd [nt~rnational
Pharmaautkal Federation. Nk~, Frana. Mf<ISftlp~ Pharrr.aci>t5,
3(2).
Bottle .. K. ( 200I }.A remlution in 8'nrtk.: Changing medicine.
changingli...... Phy,ki"" &.>ru.i ..., 17. 5lki3.
Buxton. I. L. O. (Z006) . Pharmacokinrticsand pharmacodynamic>:
Th~ dynamics of drug absorption. distribulion. action. and
dimination.ln L L. Brunton. J. S.l.azo, & K. L Parker (Ed . ),
Goodma" 0- Gilman', The pharmacological basisofth"'''/><Iltic.
(lIth ed . pp. 1-40). !*wYork. NY: McGraw-Hill.
du Soukh. P. (2001).ln human therapy. i. the drug--drug interaclion
orth~ adver,.. drug r"'Clion the issu.1 eamuJ/an Jollrnal "f
Clinical Pha1"1tl<lro/ogy, 8, 153-161.
Ginwurg. G. 5. & McC.rthy.l. J. (2001). Per50naliud medicine:
R~",I"t;"ni7.;nE ~nlZ
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St.im~r.
Chapter 6
ikrman. A. J. Snyder. S. Kozier. B.,& Erb, G. (2008). Kozkr 0- Erb',
Mlnd"","M'''!. ofNllrsinS OmrPt5, f'rI:>a ... and Practia (8th ed.).
Upper Saddl~ Ri,."r. NJ: Prentia HaU.
DAmica. D. & Barbarilo, C. (2(07). H ... lth and physical a.,..ssrn ~nt
in nursing. Upptr Saddle RiY.r. NJ: Prentic. Hall.
Gardn~r. P. (2003).Nwrnns pro<:"" in ac,;""'. New York, NY:
Thompson Ddmar Learn ing.
HOj!)ID. M.A., Bowles,D . & "''hit~,J. E. (2003 ).Nu"ing
fimd~m""tal" Revitw' 6ratimtale,. Upprr Sadd.l~ Ri""r. NJ:
Pmllia HaU.
Jahrau .. D. Sokolo>ky. S. Th urston. N . & Guo. D. (2002).
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c.a","-", ,,,,,-,"wing rMlia'"m .h"",I'Y. r.anc...... /oI1l"i"/I. 24(4).
266-275.
North American Nursing Diagno.i.A,sociation. (2003). Nu"iMg
diagnow: DefinitwnsaMd c1a"ijka.im. 2003--2004. Philadelphia,
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Smith. S. E, Duell, D. J. & Martin. B. C. ( 2004). aiMical MU"mS'Wt.
(6th ai). Up",r Saddl~ Rh."r. NJ: P",mia Hall
Wilkin""n. J. M. (2005). Nursing di<lgrwsi, handbook: NIC
iM.e"""";"',, and NOCou.eomes (Sth ed.). Up",r Saddl~ Ri""r,
NJ: Pr~ntic< Hall
Wilkinson. J. M. (2007). Nllrsi~sproce.., and m.i",1 thinking (4th
~d.). Upper Saddl. Riv". N J: Puntice" Hall.
Chapter 7
Am~rican A.cad~my of
AI'P"OOlxC
Chapter 8
Andru" M. R., & Roth, M. T. (2002). Health literacy: A revi~.
Ph~,",~cl"herapy, 21(3), 282- 302.
Chen, J. (2002, Oc!ober 20-23). Th. rokoferhnidtyill m.dk:~rUm
U.IC. Papc:r presented at the Amcrkan College of Qink.iil
Pharmacy 2002 Annual Mting, Albuquerque, NM.
Davidhi1.3r, R. (2002). Strat~ies for pro\"iding culturaUy appropriate
pharmaceutical care to th~ Hi..,..nic patienL Hospital Phanna<y,
17(<;).
<;O'>-~lO_
Chapter 9
Bates, D. w., Clapp, M., Federico, E, Goldmann, D., Kamhal. R.,
l<rndrigan, C., & McKenna. K. J. (2001). Medication ~rrors and
adverse drug event. in pediatric inpati~nt . loum~1 of the
American Medical AJsod~twn, 285(16), 211 4-2120.
Berman.A. J., Snyd~r, S., Kozier, R, & Erb,G. (2008). Kczkr& FIb.
Fundamentals ofNut>in8 Conup .... p"",tsJ and Practice (8th ~d. ) .
Uppcr Saddle Ri,'Cr, NJ: Prentice Hall
Burn.,I. P., Mitchdl, C.,Griffith, J. l., & Trung, R. D. (2001). End-oflife ca", in th~ pediatric int~n.h.., ca",: Mtitudes and pnct ices of
pffiiatric critiml care physicians and nur.... Critical C.r~
Medicine. 19(3}. 658-664.
Comminee on Drugs and Commiu on Hospital Care. (2003 ).
P",vcntion of medication ~rrors in the pediatric inpatient .. uing.
PediaJrb, Ill, 431-436.
Fedrral DrugMm inistJ"3tion. {200 I, (ktober I). Mod error
"'pons to FDA show a mixed bag. Drug Topics. Rotri.,..d from
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Kdatives.ln L. L Brunton, l . S.I.aro, & K.. L Parur (Eds.),
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BlIn:tein.A. H., HOOon. R. L.. Dunn. T..AIfaro. R. H~ Pi",itcU~ S.c.,
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major depression: A doubleblind. plactbo.-wntrollcd study in
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randomiKd. multicntlJ1". pJabo.oootrollrd study.
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Chapter 18
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a,ut~ and chron ic: pain: Focu, on drug intera.ctions and pati~m
spccifi, pharmacothtrapcutic .. lection. Sou,her" Medical Jourtuil.
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",/i<p'" prevrn"on for oplold <kpm<k~u (abbreviated ,..,,,Ion).
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Chapter 19
Alqa",er.A..A.lyahya,A .. & Ander6son. L (2006). The effect of d"""
and b..nzocain. ""r.rus placebo a, topical an .. thtlics. "'urtllli of
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Chapter 20
Abou, Alzheimer'. Relrieved from http://www.alzfdn.org
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(200l. Apr:D 1 I). Retrieval from
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Chapter 21
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Chapter 22
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DysI;pidemia c.o5Im,IIII,. Royal Oak, MI: Physician', rr. ...
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.fkcts of gra~.<d proanthocyanidins. baicalin, and wogonin.
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plw"""",I"KY. (2nd ~d.). Up~r Saddle River, NI: Pr~ntice
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""'i,
Chapter 24
!r.lbert. N. M. (2006). bidrnu-basl nursing care for pati< nt.with
heart faUure.AAG.V Ad"m",d Cririt:al Care, 17(2 ). 170-/85.
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Oiang,A. B., & Glomb. W. B. (2006). Guid.line. fore ...... luating
chronic cough in p<diatrics: ACCP eYiden~ -basrd dinical
practice guiddin ... Chm, 129(] Suppl. ), 260S-283S.
792
Appl'rKIlxC
H"}'drn, M., & Womact. C. (2007). Carina lOr p~tl"'15 WiTh aU<rgi<:
rhinitis. /ow"",1 of rIu A", ... ie"" Aa>dt"'Y of Nurse />mc.irionm,
19(6).290-298.
Nathan, R.A. (2003). Ph.armacOlherapyfor allerile rh.iniTi" A critical
rni<'W of Irukotrirnr recrptor antasonbu compart<! wiTb othrr
trraTmrnts.A"""hof AI/av, As,h""" "lUi {..,",wn%gr, 90(2),
182---190.
RalMr,P. H. ,StoIoff, S~ Mdttr, E.O~ II< tWloy,l. A. (2007).
Intranasal corlkosterokh In thoe trralmonl of aIIngk rhinitis..
Chaptar39
Allman, E. E. (200-1.). Updale on COPO. "Ibday'i stratralrs in,pro""
qualily of lif.. Advaoo: jJr Nurse i'mfti.iontrS, 12()), 4')..5 4.
IJ.ana, .. t. N. t LUtfl). l1l,ldhood a5\hma pnt one; [nilLO! a .... mont,
diagnosis. and education. fow trlill ofPtdiDrrie H",/,h 0:1 .... , 11(1),
44-48.
Colli, B. (2003). PIWr",IIC/I,hcmpy i" ,hro"j; /lbm",';"" pulmonary
dimur. Nnv York. NY; Marcel Dtl<.ktr.
loint 11Isk 1'0"", On Practiee P~ran ..mfJ I!tp~senting theAn""rkan
Acad~my of AUe'llY, Asthma, ~nd Immuoology, the American
CoUrgrof AlI~rgr,A~hma,and lmmunolosy,and thr /<:>Int Council
of AlI~rgy,Asthma, and Immuoolof!y. (2005 ~ Obtainin, optimal
....thma control: A practice panmrtrr. fo~trw ofNk'1Y~..d ailliral
Im"'wnolov. Rclrin"rd Septrmbrr 4, 2008, from htTp;J/www
.jacionlinr.org/-tlllkslinu8fJljoumillslY~WI54 12.pdf
N,,"'ne.
..uun.
c. ..
Chapter40
Chaiyakunaprut. N., Nathlsuw.n, s., Lprakobboon, K, &.
Ll.ixttall"Ol, C. (2006). Thr tfflc:acy of Binser for tht prt""ntion
ofpostoprratrn ... usa .nd 'o'OI1liting:: A mrtll-.nalysiL Amni<,,~
jourrtalof~ricsIUldGrmmLotr, 194, 9S---W.
LibraryPirate
Chaptlu 41
Barclay, L. (2007). Now guidelines for t~~l menl of (rriwble bowrl
.yndromr in adulTS. M.dICQ~ M.diml N<W5. Ildritvtd August 15,
2008, front hltp; lIwww.mcd>Capr.oom/";("W.rtkl~/556356
~, B. G.. Dio:cqraok. B. K, & H....alll.'r, S. B. (2006~ Alw"rns ill
111. 'rm"...,,' ofCrohM'sdismse: from ruurdr ,0 ,linit,,1 pmcrirt.
707_ 71~,
717_ 711l.
r.
AI'P"OOlxC
793
ChaptQr42
Schori-Ahm.d, D, (2003), Dd.n .... gone awry: Thyroid di ..a .., RN,
66(6),33--43,
~kGraw- HiU,
Chapter 43
Andrioli, M"Gir.. ldi, F. p" Ik Manin, M" & Ca.-agnini, F. (2007),
Th~rapies for aodn:nal insufficim<y, &perr Opitlion on Therapeurk
PII ,m", 17(1l), 1323--1329,
Dahlg",n, I" & Wildand, K,/r,. (2005), Final height in short child"n
born smaU for gestational age trtaud with growth hormone,
Prdi~"i< RSfarrh, 57(2), 216- 222farwell,A. p" & Bnovcrman, 1.. E, (2006), Thyroid and ~nti.hyroid
drugs, [n L, L Brunton, I, S, law, and K, L Park.. (Ed.,),
Goodnwn'" Gilman, The pharmamlogical b!ui, of,herapeurk.
(11th ed" pp, I 511 - 1540), New York, NY: McGraw- HilL
Griffith., H" & lordan, S, (2002), Corticost~roids: Implicatio n. ror
nursing pra<tice, Nursitlg Standard, 17(12), 43--53,
LibraryPirate
ChaptQr 44
American Diahet~.A>so<:iati()n, ( 2007 ), From i",ulitl to ,nemi",: A
reR" from ,iii' 67th Scien,ific Se5SWn of the Ameriean Diabe""
A",x"',k,", Chtcago: Author,
Bates, N, (2002), Ovrnlo.. of insulin and oth~ r diabetic m~dication,
Emergency Nurse, 10(7), 22- 26,
Bohannon, N, I, V, (2002), Treating dual defocts in diabete" Inrulin
",~istan'c and insulin .."ction,AtnerialniourrIIllofHalllhSystem Pharmacists, 59(SuppL 9), S9-513,
Co,ta, j" Borges, M" David, C, & Carneiro, AV, ( 2006), Effi<acy of
lipid lowering drug tn:a!mom fordiabeti< and non-diabetic
patients: Mda-analysi, of randomised wmrolled trials, Briti.h
Medical Journ~~ 332, 1115--1124,
Davi., S, N, (2006), Insulin, oral hYJlO8lycemic agmts, and th~
pharmacology of tho ~nd<Krine pan"n:as, [n L L Brunton,
j, S, Law,and K, L Par~r ( Ed,,), G""dm~n'" Gilman', The
pharmacological ba,iscj therapeu,ic. (ll!h~d" pp, 1613--1646),
NewYo,k, NY: M<Graw- Hill,
Fdg, D, S" Briggs, G G, & K<>r~n, G, (2007) , Oral antidiabetic agents
in pr<'8nancy and lactation: A paradigm shift? Annill. in
Pharmacomerapy, 41 (7), 1174-1180,
Gn:ger""", S" leppe><n, p, 8., Hol,t, I, I" & Horman""", K. (200t),
Antih~rgll"emk effects of s!e .. io,ide in ty~ 2 diabetic subjc:cts,
M.",boli>m, 53(1), 73--76,
Hjelm, K. , Mufunda, E., N.mbor.i, G" & Kemp, I, (2003), fuparing
nurse. to fa the pand.mic of diabetes mellitus:A lit.ratu",
",view, J"umal ofAd,'anced Mming, 41, 424---435,
H",,,,n., M, M" Tam""a,l, T" Iki,huiz.en, E, D., & Hui,man, M, V,
(2005), Pharma<ologkal strat~8;" to reduce cardiovascular ri,k in
t~ 2 diabetes m~Uitus: An updat., Drug., 65(4),433--445,
Md Cnigh.-" k nd, [I" s..b ..lm, S" & Kdly, S, D, (200~), Tho un: of
drlldren and adolescent, with ty~ 2 diabetes, Jou"",1 ofPediotrk
N~rsing, 20(2), 96-1[)6,
Mokdad,A, H" Bowman, B, A., & Ford, E, s, (ZOOI), Thcwntinuing
'pidrnlicsof obesity and diabetes in tit. United States, /oIIrnlll of
the American Medical A,,,,da,wn, 286, 1195--1200,
VandeLaar, EA"Ak~rman., R. p" & van Binsbergtn, I, I, (2007),
Umit. d evidence for ~ff~clS of diet for type 2 diabetes from
systmlatic reviews, Europetln Jourtl~1 of Gitlical Nutritiotl, 61(8),
929-937,
Chaptllr45
Davidoon, M, R" London, M, L, & ladewig, p, L (2003), Maternal
newborn nutsingand ""mm', hMlth ae", .. the lifo,pan (3th
ed,),Up~r Saddl~ Ri..er, N I: Prmtke HalL
David, p, S" Boatwright, E,,,-,, Tozer, B, S" V~rma, D, p" Blair,
j, E" Mayer,A. P"et al. (2006), HOfDlonalrontra<<ption update,
M~yo Clinic Proctdings, 81(7), 949-955,
ErUola, R. (2007), Recent advance. in hornlOnal contraception,
Cur"'nt Opinion in Ob'tNri &Gynecology, 19(6), 547- 553,
Han .. n, L 8., & Portman, D. (2006), Hormone thet'apy update:
Current recommendation. rorm.nopausal symptom" US
Ph~rn'~ci!"
31(9), 119--')6,
Lttman, L" Fontaine, p" King, V" Kldn, M, C, & Ratcliffe, S, (2003),
natun: and management oflahor pain: Part II, PharnIaCOlogk
pain n:lid,American Family Phy.icultl, 68, 1115--1120, 1121 - 1122,
Loo .., 0. S" & Stancel, G M. (2006 ), Estrogen., In L L Brunton,
j, S, Law,and K, L Par~r (Ed,,), Goodman ... Gilman'. Th.
n..
794
AppeoolxC
"Ir"
Chaptlllr46
lknt, S., Kane, C., Shinohara, K., Nrnhaus, r., Hudes, E. 5., G<!ldbag,
H., &Avins,A. L. (20(6). Saw palmeno for ""nign pro<latk
hyperplasia. Neo. England lournal ofMedkine, 354(6 ), 557- 566.
Bullock, T. L, &AndrioJr. G. L. (2006 ). Emergingdrug therapies for
brnig.n pro.tatic hyperplasia. Xper< Opini<m "" ~<J' D .... g<.
1I(1),lll- 123.
Carri.., S. (2003). Pharmacology of pho.phodirsteraso 5 inhibitors.
Canadian klu,nal ofUrelov: 100Suppl Il. ]2- 16.
Ficordli, C. (2007). Untangling thr complexities of male infurtiUty.
Nu"ing, 1007, 37(1), 24-26.
Gordon,A. E., & Shaughnessy,A. E (2003). Saw palm<l!o for
pro,tate disorde .... A"'N'ican Family Phy,icu"" 67(6), ] 281 - ] 283.
Kassabian. V. S. (20(H). Sexual function in patients trealed for benign
pro,tatic hyperplasia. r..nc~ 361(9351), 6(ki2.
Kltastgir,J.,Arya, 10.1., S~rgill,1. S., Ka.lli,/. S., Minha .. S., & Mundy,
A. R. (2002). Current concepts in the pharmacothrrapyofbrnign
prostatic hyperplasia. XP"' Opinwn on Ph"rnuu;othmlpy, 3( ]2),
]727- ]737.
Mdeod, D. G. (20(3 ). Hormonal therapy: HiSiorical persprctivr to
futuro direction . Urol"SY, 61(2, Suppl. I), 3-7.
Snyd~r, P. J. (2006 ).Androgcns. In L. L Brunton, J. S. Lazo, and
K. L Parker (Ed.o.), Goodman ";'Gilman', TM pharmaroklgical
basio ef,h",aproric. (]]th ed., pp. ]573-1586). Now York, NY:
McGraw-Hill.
Sprncer, M. (2007, March JO). Managc:mem of errctil~ dysfunction
in primary",..,. GP: Gen"",II'rtlNitiour. 36- 37.
Steiner, B. S. (2002). Hypogonadism in mcn.A rrnowof diagnosis
and tn:atmem. AdwlMct< for Nu"" Priu:titicn"", 10(4), 22- 27, 29.
Chapter 47
Burke,A., Smyth, E. M., & Fj~rald, G.A. (2006).
Analgcsic-antipyretic aunts; Pharmacot~rapy of gout. In
L. L Bn..tnton, r. S. Lazo,and K. L. Parhr (Ed . ). Good",~" ...
Gilman', 1"/", p""","""ological basio ef th"",putics (] ] th rei.,
pp. 67] - 716). Now York, NY: McGraw- Hill.
Clegg, D.O.. Rla, D. J., Harris, C. L, Klein, M.A., O'Ddl, I. R.,
Hooper, M. M., ... & W~liam H. J. (2006). Gl"", .. mine,
chondroitin sulfate, and the two in combination for painful kn
osteoarthritis. Neo. England klurna/ ofMedicin', 354(8), 795-f108.
CUrry, I.. c., & Hogslel, M. 0. (2002 ). OSiooporosis. Amerirll7l
10u"",1 efNurs;ng, 102. 26-32.
Friedman, P.A. ( 2006). Agc:ntsafftcting min<r~l ion homeosta.is and
bonr turn"""r. In l. L. Brunton,l. S. Lazo.and K. L Pdrker (Eds.),
Good",an &- GiI"'''n', The ph"rm<>cologic,,1 bas" eftherape~tic,
(] Ith ed.,pp. ]647- ]677). New York, NY: McGraw- Hill.
Kuehn, B. (2007). Knee therapi .. probed. lou"",/ eftlu Amfritwo
Medical A.ssocillrion, 29ii(20). 2361.
LibraryPirate
~,c.
Chapter 48
Bayliffe, A. I., Brigandi, R. A., VI"tlkin .. H. /., & lfvkk, M. P. (2004).
Emaging therapeutic targets in psoriasi . Cu,""'t Opinion' in
Ph~rmlll"ology,
La""",
ChaptQr49
Anterican Academy of Family Phy,icians and American Academy of
Pediatrics. ( 2004). Diagn""" and ""'nage"",n, of at1t,e e,iti, medic.
lktri"... d September 8, 2008, from http://www.aafp.orglonline/
en IhonlC/clinicall din icaln:-c",aom.html
Brs, S. L, & Abramo, T. /. ( 20(4). Otiti xterna review. I'fdiarri<;
Emers""<Y CAre, 20(4) , 2>0-256.
Fingc:re{, M. (2007). Undemanding glaucoma medication .. Rview
efOptometry. 144, 13- ]5.
Frirdman, D. (2007). Primaryangk dO,Un:-glilUOOIllil. RITieo.ui
Optometry, 144, 26-27.
H"nd . .. c,). D.,S. Ropuano, C.). (2006). Ocular phumacolosy. [n
L. L Brunton, /. S. Law, and K. L. Palker (Ed .. ), Goodman doGilm"n:' The ph,,'macologic,,1 00.;. ef th"",pe~t;'-' ( 11th ed.,
pp. ]707- 1737). Now York, NY: McGraw-Hill.
McCartor, D., Courtney, A., 8< Porta, S. (2007). Cernmm impaction.
AmN'ican fumily Physicitln, 75(10), ]523- ]528.
Osguthorpr, r. D., & Nid .. n. D. R. (2006). Otitis extema: Rc ... iowand
clinical updat~.Ameria", Family Physician, 74(9), 1510-1516.
Schw.nz., K.Io.., & Bud. nz. D. B. (2004). Current managemmt of
glaucoma. Curr~n' Opinicn in Oph,lwlmcltJsy, 15(2) , 119-]26.
Tripathi, R. C., Tripathi, B. J., & Haggc:ny, C. ( 2003). Drug-induad
glauwmas: M~chanism and managc:ment. Dntg5llfrty, 16(]] ),
749-767.
Wrighl, /. (2005). Common ear problem' in the primary care .. lIing.
]0""",/ efCAmmuni,y Nursing, 19(9). 4J.--46.
Appendix 0
cologie; an oral contraceptive is therapeutic; a laxalive is
therapeutic; a folic acid antagonist is plulrmacologic; an
antianginal agent is thenpeutic.
ANSWERS
Chapter 1
AnS\<l'~rI
The patient may choose OTC drugs nth"" than more ef~
ore
Rationale: The enteral route involves the process of swallowing by definition. Cognitive Le.'eI; Comp rehension.
NUNing PrCH:eu.: Assessment. Pali~tli Nerd: Health Promotion and Maintenance.
3
A/U~r:
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nre, all the answers al't correct. but one should stand oul as
the first action the nurse should take. Think about patient
safe ty. In this example. the d rug luis been nMY p rescribed;
thel'tfore, notifying the health care provider of the patient's
reactio n takes priority SO that new medication orders can be
received to add/l.'55 the allergic reaction and to discontinue
the present order. Cognirive u,-eL Analysis. NUNinR Proem:
Implemmlation.l'fIril'"t Need: Physiological Integrity.
796
AppeoolxO
4 NtSWer: 2
\'lhile a patient who is NPO for surgery is not usually allowed anything to eat or drink, crucial medications such as
drugs to control blood sugar may be allowed or a different
form (e.g., insulin by injection) may be givt'n. The nurse
should contact the health care provider and check if any additional orders are needed. Cognitive Level: Analysis.
Nursing Process: Implementation. Pa tient Need: Physiological Integrity.
Answers to Critical Thinki ng Q uestions
Although the nurse is responsible for safe medication ad ministration, errors continue because many disciplines
are responsible for safe and accurate drug administration.
Many steps are involved in the safe administration of
medications, and there are multiple points where errors
can occur.
2 To help ensure drug compliance, the nurse and patient
Rationale: Some medications can be affected by foods, bewrages, or other drugs. The effect of calcium, iron, and magne.iwn on ~ tetracycline ~ntibiotic i< an e""mple of a food-drug
interaction thM OCCllrs in the ah_<Clrption pm"""' _
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2 Answer: I
Rationale: The blood-brain barrier may cause difficulty in
treating tumors. Most antitumor medications do not cross
the blood- brain barrier. Cognitive ul'el: Anal)'Sis.
Nursing Process: Assessment. Pm ien t Need: Physiological
Integrity.
3 Answer: 1
Appendix D
797
Chapter 5
Chaptllr6
I Answer: 2
I Answer: I
Rationale: NANOA classifies a nursing diagnosis as a clinical judgment about individual, f~mily, or community responses to actual or potential health/life processes. Per
NANOA, nursing diagnoses provide the basis for the selection of nursing interventions to achieve outcom... for which
the nurse is accountable. Cognifile Lewl: Analysis. Nursing
Process: Assessment. Patient Need: Health Promotion and
Maintenance.
Rationale: An antagonist occupies a receptor site and prevents endogenous chemicals from acting. An agonist produces the same type of response as the endogenous
substance. A partial agonist is a medication that produces a
weaker response than an agonist. Cognitive Lewl: Application. Nursing Process; Implementation. Patient Need:
Physiological Integrity.
3 Answer: 2
2 Answer: 2
5 Answer:4
Rationale: A drug that is more efficaciou5 produces a higher
maximal response. If other drugs for pain were not effective
in relieving the pain, morphine would be considered to have
a greater efficacy in relieving this type of pain. Cogrritil-e
Level: Application. Nursing Process: Implementation.
Patient Need: Physiological Integrity.
6 Answer: 2
A narrow therapeutic index indicates that there is only a
small amount of difference between the dosage needed to be
effective (EO,,) and the dosage that will be toxic (LO,,). Extra caution should be taken with drugs with a narrow ther~peutic index to ~void giviJlj,lan exce&6ivedose ~nd to ensure
4 Answer:4
Rationale: Evidence of therapeutic benefit (i.e., efficacy) is
the most important factor to assess when evaluating the ef
fectiveness of any medic~tion. Cognitile Lelel: Application.
Nursiug Process: Evaluation. Patienf Need: Physiological
Integrity.
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798
AppeoolxO
5 N,swer: 4
Rarionale: The purpose of evaluation in the nursing process
is to determine whether the goals and outcomes have been
adequately met by the patient. Cognitiv e Le,'el: Application.
Nursing Process: Assessment. Pa tient Need: Health Promotion and Maintenance.
6 Answer: J
~pt'cial
ChaptQr 7
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Ih"rdl'<"uli~
1 Answer: J
Rationale: Isotretinoin (Accutane) is FDA pregnancy category X and is contraindicated during pregnancy. It should
not be used at all during pregnancy. Cognitive Level: Application. Nursing Process: Implementation. Pa tient Need:
Physiological Integrity.
2 Answer:4
Appendix D
6 Answer:]
Rationale: V-.'ith each visit, the nurse should take a medication history of aU OTC and prescription medications, noting any new medications not previously mentioned. A
pharmacy history" will draw atto:>ntion to tho:> possibility
that the patient is obtaining medications from more than
one pharmacy, a potential problem in polypharmacy.
Cogllitive Le~el: Analysis. Nursillg Process: Implementation. Patiell t Need; Physiological Integrity.
Answers to Critical Thinkin g Q uestions
Pyelonephritis is frequently associated with preterm labor in pregnancy. Before initiating antibiotic therapy, the
nurse should first determine the fetal gestational age.
The potential for a drug to be teratogenic is highest during the first trimester. The nurse should also look up the
pregnancy classifica tion 01 the antibiotic. Selected agents,
such as tetracyclines, should not be used during pregnancy. The nurse should address any concerns regarding
the drug category with the health care provider.
2 Prior to considering a sedative agent, the nurse should assess the patient for other physical causes of confusion. For
example, in the frail elderly, alterations in electrolytes,
drug side effects, and rapid environmental changes can
contribute to confus ion. Attempts at reorientation should
be made. The nurse should determine how diazepam
(Valium) is distributed and metabolized. Valiwn is a fatsoluble drug; thus, because elderly patients have increased
total body fat, the drug has a much longer half-life. In addition, numerous drugs decrease the metabolism of diazepam and may contribute to an increased half-life and
enhanced CNS depression. If sedation is deemed necessary, other drugs should be wnsidered.
3 The nurse should consult with the providerorpharmacist
regarding the need to repeat the dose. Many oral e!i:tirs
are absorbed, to some degree, in the mucous membranes
of the ora1 cavity. Therefore, the nurse may not need to repeat the dose. Acetaminophen can also be toxic to the
liver in doses only sl ightly higher than normal and extra
caution should be used for all drugs containing acetaminophen. The nurse should consider using an oral syringe to
accurately measure and administer medications to infants. The syringe tip should be placed in the side of the
mouth, not forced over the tongue. Conditions affecting
the GI tract, such as gastroenteritis, can affect drug absorption because of their effect on peristalsis.
ChaptQrS
799
Ratianale: Writtt'n materialsallowtht' patient and fumilyto review information on additional occasions at borne, but up to
48% of English-speaking patients do not ha~ the basic ability
to read, understand, and act on health infomlation. This rate
is even higher among non-English-speaking individuals and
older patients. The nurse must be aware of the patient's literacy level and take appropriate action to ensure that information is understood. An assessment of visual impairmt'nt
should also be made and large-print matt'rials provided when
necessary. Cognitive Lel'f~l: Assessment N ursing Process:
Analysis. Patiellt Need: Health Promotion and Maintenance.
3 AIIS",er: 2
Rmiollale: When patit'nl5 have strong spiritual or religious beliefs, these may greatly influence their perceptions of illness
and their preferred modes of treatment. III health and spiritual issues can have an impact on wellne:ss, nursing care, and
pharmacotht'rapy. Coglliti~e !.n-el: Analysis. Nursing
Process: Assessment. Pafien t Need: Psychosocial Integrity.
5 Am",er: 1
Rationale: Slow acetyiators experience a delay in drug metabolism in the lher. This can caust' the drug to build to
toxic levels and result in drug toxicity. Coglliti>-e u~el: Application. Nurs illg Process: Evaluation. Pa tient Need: Psychological Integrity.
6 AIISwer:4
Rationale: To treat a patient holistically, the nurse seeks to
undt'rstand the multiplt' factors that may contribute or help
solve a specific patient problem. By asking for the patient's
own evaluation of the problem, the nurse can detennine the
severity of the problem and the impact it has on normal activities. These determinations help to develop a plan of care
specifically tailored to individual patient needs. Cogn ith-e
!.nel: Application. Nursing Process: Assessment. Patie nt
Need: Safe, Effective Care Environment.
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800
AppeoolxO
6 Answer: 2
Rationale: This approach best ensures a ooUaboration between the nurse and patient, allows the nurse to ensure the
medication is taken, and provides an opportunity for the
nursl.' to teach the patient about the medication. Cognithe
Level: Application. Nursing Process: Implementation.
Patient Need: Safe, Effective Care Environment.
ChaptQr9
Rationale: Nurse pract ice acts encompass all aspects of nursing, including the definition of professional nursing, medication administration, and definition of standards of care.
Cognitive Level: Analysis. Nursing Process: Implementa tion. Patient Need: Safe, Effective Care Environment.
2 Answer:]
Rationale: The nurse is responsible for docwnenting medication errors and completing an incident report for review
by the facility's quality assurnnce personnel. Cosniti,e
Level: Analysis. Nursing Process: Implementation. Pa tient
Need: Safe, Effective Care Environment.
3 Answer: I
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App<>ndlx D
I'[".. di~" ... r" amI "rr.,..uv" <.Irug a<.IIlliJJ.i~tratiull, all Ill"Illbers of the health care tt'am must work togE1:her to ensure
80 1
tients are taking two or more drugs, one of which is a selective serotonergic medication. Synlptoms include agitation,
dizziness, sweating, and headache. Patients should discontinue use of tht' medication and seek medical care immediately. Cognitive Lelel: Analysis. Nursing Process:
Assessment. Patien t Need: Physiological Integrity.
6 Answer:J
Ratiol/ale: Specialty supplements are nonherbal dietary
products used to enhance a wide varie-ty of body functions.
In general, specialty supplements have a legitimate rationale
for their use. But tht' link between most specialty supplements and their claimed benEfits is unclear and the body
may already have sufficient quantities of the substance. Taking additional amounts may be of no benefit and large
amOWl1S of some supplements may be harmful. Specialty
supplements may give patients false hopes of an easy cure.
Cognitive Ul't:/: Comprehension. Nursing Process: Implementation. Pafient Need: Physiological Intt>grity.
Chapter 10
Rationale: Natural products contain many active ingredients, many of which havt' not been tested or identified. Patients with known allergies to food products or medicines
should seek medical advice befort' using herbal supplements. Dietary supplt'ments must state that tht' product is
nOI intended to diagnose, treat,curt', or prevt'nt anydist'ase.
Cognitive wel: Analysis. Nursing Process: Implementation. Patient Need: Physiological Integrity.
J Answer: 2
Rationale: Serotonin syndrome is a rare but potentially lifethreatening medical condition that may occur when pa~
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Answers to NCLEX-RN@>ReviewQuestions
I Answer::!
Rationale: Some patients and health care professionals believe
that therapeutic use of scheduled drugs creates large numbers
of addicted patients. Prescription drugs rarely cause addiction when U'ied according to aa:epted medical protocols. The
risk of addiction for prescription medications is primarily a
802
AppooolxO
2 Nuwer: 2
Rationale: ToIl'!"anc:e is a biologic condition that occun when
the bodyadaplS 10 a subslalXe aftl'!" repeated administration.
Ovl'!" time, higher closes of the drug are required to prodoct'
the samt initial efftct. CDgltitil~ uw/: Application. NUNi"g
Process: AMessmmt. Altim! Nd: Physiological Integrity.
3 Answer:"
4 Allswer: J
malignant hyperthermia, which can lead to muscle damage and renal and cardiovascular system failure. Physical
symptoms ofMDMA use include muscle tension, nausea,
rapid eye movemenl, faintness., chills. sWeOlting, increased
heart rale and blood pressure, and involuntary teeth
clenching.
2 The
NIDA
InfoFacts
sheet
on
steroids
(www
Cha tllr 12
Answers 10 NCLEX-RN" Review Questions
] Answers: J, 5
Rationale: Anthrax affects therespirntory system . Fevl'!", peTsisknt cough, and dyspnea are all initial sym ptoms of inhaled. anthrax.. Cognitwe Le"el: Analysis. N urli"g Prouu:
AMessment. Patielft Nud: Physiological Integrity.
S Answers: J, 2, "
2 AlfSlO't'r: 2
ity, anxiety. restlessness, hea<:bches, increased appetite, insomnia, inability to ooncentrnte, and a decrcaw in heart rnte and
blood pressure. Cognitil'e Leve/: Applkat ion. Nursinf{ Process:
Implementation. Pntient ~d: Physiological Integrity.
6 Answer: 1
Rationllle: Overstimulation of the oeurotransmitter acetylcholine causes convulsiol15 and loss of consciousness within
Ratiollllle: Phpical dependence and psychological dependence may occur together and r~sult in drug-seeking behavior. But physical dependtnce occurs as the body adapts to
the substance such that withdrawal sym ptoms will occur if
the substance is stopptd. Physical withdrawal symptoms do
not occur with psychological dependence altllough an in
tense craving for the substance may be felt. Cognit;"e Le"e!:
Comprehension. Nursing Procel$: Assessment. Patient
Need: Physiological Integrit y.
Answers 10 Critical Thinking Questions
The NationailnSlitute on Drug Abuse offeTS a link titled
Info Fact&, which provides a grut deOll of information
about MDMA (www.drugabuse.gov ).This drug is a neurotoxic agent. When taken in high doses it ca n produce
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3 Answer: I
seconds. Cognitive Level: Analysis. Nu'sillg Procell: Assessment. Patimt Need: Physiological Integrity.
4 AnSlO't'r: 3
Rationale: The antibiotic cipronoxadn (Cipro) has been
used for both prophylaxis and treatment of anthrax.
Cognitivl Lel'e/: Analysis. Nursing Pf'()ess: Planning.
Pafient Need: Physiological Integrity.
5 An",oer: 2
App<>ndlx D
6 Answers: 1,2,4,5
m~int~ining
Cllrrent knnwledge nf
resources, and in the early detection of possible emergencyconditions. Through educating their patients, families, and communities, they are also a primary source of
information in the prevention of poisonings or for earl)'
treatment.
Chapter 13
Answers to NCLEX-RN'" ReviewQuestions
1 Answer: 1
Rationale: Adrenergic agonists stimulate the sympathetic
nervous system and produce symptoms of the fight-orfliJl,ht response. Nausea, vomiting, nervousness, bronchial
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Rotionale: Overdosage of parnsympathomimetics (cholinesterase inhibitors) may produce excessive sweating, drooling, dyspnea, or excessive fatigue. These symptoms should
be promptly reported. Cognithe Level: Analysis. Nursing
Proem: Assessment. Patient Need: Physiological Integrity.
804
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Cha
IIr
14
5 A nswer: 2
Counseling or behavi oral techniques such as stress reduction will assist in addressing the underlying problem and
help ensure the drug is not taken longer than necessary.
Benzodizepines are not stopped abruptly or rebound an.:uelf or cardiovascular effects may occur. Cognitive LntI:
Analysis. Nursing Proc.. ,,: Evaluation. Altie .. t Need: Physiological Integrity.
Answers to Critical Thinking Qunlio ns
Pain is empha5ized as being the fifth vital sign. The assessmmt and appropriate man.;J.gement of pain is a nursing
function. A nurse might be templed 10 give this patient a
sleeping media tion alone, fearing 1M side effects that
might occur if given in combination with an opioid narcotic. Secobarbital is a short -act ing barbiturate. Barbiturates are not ~<'C1ive analgesics and sefK'rnily do not
produce significant hypnosis in patients with sewre pain.
The barbiturate may intensify the patient's r!.'action to
painful stimuli. Administering a barbitunte with a potent
analgesic appea rs to reduce analgesic requirements by
about 50%. The nurse may oeed to consult with the health
care provider regarding lowering the dose of narcotic.
2 Lorazepam (Ativan ) is USI as an antianxiety agen t but it
4 Answ.-r; J
crn.
not be s topped
abruptly. The health care provider should d ecide when and
how to discontinue the medication. Cogniti" e Lt ..tI:
Analysis. Nursing Process: Evaluation. Patient Nd: Phys-
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I AlfSlO't'r;
Appffidlx D
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Chaptllf 16
Answers to NCLEX-RN@> ReviewQuestio ns
1 Amwer:4
Anticholinergic effects such as blurred vision, dry mouth,
and constipation may occur during the first weeks of therapy. ToleI'3nce to anticholinergic effects tends to develop after seVl:!ra] weeks of regular use. They can be managed
symptomatically by increasing fluid intake, being cautious
with activities that require visual acuity (e.g., driving), and
increasing fiber in the diet. Psychomotor symptoms, tachycardia, hypertension, increase in respiratory rate, and tardive dyskinesias are potential adverse effects of TCA
antidepressants but are not related to anticholinergic effects. Cog"iti,e Lnel: Application. Nursi"g Process: Assessment. Patie"t Need: Physiological Integrity.
2 AlI5wer: J
Rationale: Methylphenidate ( Ritalin) is a Schedule II drug
with potential to cause drug dependence when used over an
extended period. The drug holiday is to decrease the risk of
dependence and to evaluate behavior. Cognitive Level: Application. Nursing Process: Implementation. Patie"t Need;
Physiological Integrity.
3 AIISIO-ers: I, 2, 5
Rotiollale: Diarrhea, ataxia, hypotension, edema, slurred
speech, and muscle weakness are signs of lithium toxicity.
Dehydration can lead to lithium toxicity. Cogllith-e Level:
Analysis. Nurs ing Process: Assessment. Patient Need: Physiological Integrity.
4 AlISwer: 2
Rationale: Taking St. John's wort with an MAOI could result
in hypertensive crisis; patients should always consult with
their health care provider before taking any medications or
OTC drugs/herbal remedies. Cognitive Le,d: Application.
Nursi"g Process: Implementation. Patient Need: Physiological Integrity.
5 AIIS"",,r: J
Ratiollale: Nardil is an MAOI. This class of drugs has many
drug and food interactions that may ause a hypertensive
crisis. Cognitivt Level: Analysis. Nursing PrOCtss: Plalllling.
Pmi"n( N ....d' Physiological Integrity_
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6 Allswer:3
Antidepressant drugs such as the SSRIs may not have full effects for a month or longer but some improvement in mood
and depression should be noticeable after beginning therapy. Anything less than a month is too early for filII effects
although some improvement may be noticed. Cogniti~e
Level: Application. Nursing Process: Assessment. Pmient
Need: Physiological Integrity.
that the drug is swallowed. Never leave medications Wlattended in a patient's room. If there are concerns that the patient may not have swallowed the medications, ask the
patient to open his or her mouth. The risk that a depressed
patient will take an intentional overdose increases as the
medication begins to work and gives the patient more energy to carry out a suicide plan.
Chapter 17
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2 Answer: 2
Rationale: Acute dystonias occur early in the course of therapy. These are severe muscle spasms, particularly of the back,
neck, tongue, and face. Cogniti~e Level: Analysis. Nursing
Process: Planning. Patient Need: Physiological Integrity.
:1 An5wer: 2
808
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Chapter 19
Ans"'rel'll 10 NCLE.X-RN.
1 Answn: I
Rmionnle: The
2 AnsIO'er: 4
Rationalf: Solutions of lidOOli ne con tai n ing preservatives or
epinephrine are intended for local an est hesia o nly and must
never be given IV for d ysrhyt hmias. Cognifil-e bl-e/: Analysis. Nursing Proct'ss: Implementation. Pafiem Nfe/I: Physiological Integrity.
An ....er::J
Rationale: Th e first step of th e nursing proCe$S is assess -
The nu!'l;t' 5hould questio n the health care provider regarding this order. lidocaine is an appropriate choke for a local
anesthesia but not if it includes epinephrine. Epinephrine
hasalpha-adrenergic properties. is a potent vasooonstnctor,
and may cause ClIrdiaC dysrhythmias in this elderly patient.
Epinephrine istraditionally not ~ in the areasof~fi ngm.
nose, ~,and toes,~ beause these areas may suffer adverse
effects from the vzoconstricti,"t propertie$ of tht drug.
2 The nurse understands that this drug is a depolariring
medicatio n and therefore has the pottntial to increase
potassiwn release. The nurse is aw;)tt that this pa tient is
on digoxin (Lanoxin) and has renal fa ilure, and therefo re
is not a good candidate for this drug because of the potential hypt'rkalemia that may result in life-threatening
cardiac dysrhythmi as.
(hapter20
Answers t o NCLEX-RN" ReviewQutst ions
I AnSWl'r. 2
Rntionale: Extnpyramidal symptolN may be life threatening
without intervention. The patient should be immediately
transported to the emergency depar tment. DipbenhydF.llni lK'
must be given parenterally for effective treatment. The drug
dosage should nol be increased, beca~ symptoms may become worse. CognilM w-el: Analysis. NII"ing Proctss: Im_
plemI.'ntation. Pritknt Need: Physiological Integrity.
2 AnSWl'r: 1
5 AnsK'ers: I, 4
Rationale: Succinyh:holine (Anectine) ClIn ClI~ oomplete
paralysis oCthediaphngm and intercostal muscles. BradYCllrdia and respintory depression are expe<: ted. Medunical ventilation 5hould be avaiUblt. Cogniti,-e Lel'tl: Analysis. Nursing
Process: AssessmenL Ail it'" t l'-Jcul: Physiological Integrity.
Rationale: Pharmacotherapy dotS not cure or stop tht disease process but dotS im prove the patient's ability to perform normal activities 5uch astating , bathing, and walking .
Depending on th e drug thenpy, EPS m ay be an adverse ef_
feet. Cogllitile UItl: Analysis. Nurl ing Proc..u: Implementation. Ptoli~,,' Need: Phy5iologicaJ Integrity.
6 AnSIO'er: 4
3 AnSlO-er: 4
Rationale: A decrease in kidney and liver function mayslow
the metabolism and excretion of the drug, lea ding to over_
dose and to:ucity. Levodopa does not cause th e urine to turn
orange. It is not reasonable for a patient to moni tor his or
her blood pressure every 2 hours during the first 2 weeks of
therapy. Cognitivt
Anal ys is. M'Ning Pro(tu: Impl ementation. Patint Need: Physiologicallnttgrity.
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4 Answer. I
Rationale: The cause is unknown; however, str uclUrai dam_
age consisting of amyloid plaques and neurofibrillary tan_
App<>ndlx D
Rationale: Blepharospam (spasmodic eye winking) and muscle twitching are early signs of potential overdose or toxicity.
Orthostatic hypotension,drooling, nausea, vomiting, and diarrhea are potential adverse effects unrelated to toxicity or
overdosage. Cogniti,e Lend: Analysis. Nursing Process: Implementation. Patient Need: Physiological Integrity.
Chapter21
Answers to NCLEX-RN8 ReviewQ uestions
I Answers: 1,2,5
Rationale: Adverse reactions to cyclobenzaprine include
drowsine~, dizziness, dry mouth, rash, and tachycardia. Because medication can cause drowsiness and dizziness, ensuring patient safety must be a priority. Usually, patients
experiencing back pain have orders for limited ambulation
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until muscle spasms have subsided. Cogn itil-e Lewl: Analysis. Nursing Process: Implementation. Pa tient Need: Physiological Integrity.
2 AIISwer: 4
Rationale: An adV\'rse effect of botulinum is pain. The drug
is injected directly into the muscle. Pain associated with injections is usually blocked by a local anesthetic. Treatment
with botulinum helps improve muscle strength, bUltherapeutic effects are usually del~d by a few days. Cogniri,-e
Lewl: Analysis. N ursing Process: Implementation. Pll tient
Need: Physiological Integrity.
3 Amwer: I
Rationale: FJevated serwn liver enzymes should be reported
to the health care provider. Cyclobenzaprine may cause se-
Rationale: Patients should be instructed to report side effects such as muscle weakness, drowsiness, dry mouth,
dizziness, nausea, diarrhea, tachycardia, erratic blood
pressure, photosensitivity, and urine retention. Until effects are known, the patient mould not drive. II may take a
few hours for the drug to become effective. Cognitive
Level: Analysis. Nursi ng Process: Evaluation. Patient
Need: Physiological Integrity.
6 AIISM-er: I
Rationale: Muscle relaxers such as baclofen work best when
taken consistrntlyand not pm. Noting cornistentlyof dosing
helps to detemtine the appropri.1leness of dose, frequency,
and drug effects. Consumption of alcohol or increasing the
dose of muscle relaxers will increase the risk of sedation and
drowsiness. The patient's log of symptoms and drug dose and
frequency may assist the provider in determining the therapeutic outcome of the medication. The patient's report of
pain or oontinued spasms should be oonsidered an accurate
account. Cognifivt Level: Analysis. Nursing Process: Assessment. Patient Need: Physiological Integrity.
8 10
AppeoolxO
improvement in 45 days, the medication regimen is usually discontinued. In this case, the nurse should evaluate
the patient's muscle firnmess, pain experience, range of
motion, and ability to maintain posture and alignment
when in a wheelchair. When spasticity is used to maintain
posture, dantrolene should not be used. In this case, the
patient's spasticity involved only the lower extremities.
2 Answer: J
Rationale: The goal of lipid-lowering therapy is to decrease
total cholesterol and LDL, while raising HDL levels.lli
other chojces do not decrease the levels of harmful lipid levels. Cogn itive Level: Analysis. Nursi ng Process: Evaluation.
Patient Need: Physiological Integrity.
Rationale: One adult-strength aspirin taken 30 minutes before the nicotinic acid may reduce the adverse effects of
flushing and feelings of hot flashes. Taking the drug one
hour before meals with plenty of water, mixing the drug
thoroughly in water before taking, and taking other medications 1 hour before or 4 hours after the drug are guidelines
reconunended for bile acid sequestrant drugs. Cognithe
Level: Application. Nursi ug Process: Implementation.
Pa tient Need: Physiological Integrity.
n~rvOll.' "Y't~m
to dom_
inate. In this case, the result has been a decrease in oral secretions and relaxation of the smooth musde of the GI
tract. Decreased peristalsis and motility can result in constipation. The anticholinergic effect is also responsible for
urine retention because of increased constriction of the
internal sphincter.
Chapter 22
Answers 10 N CLEX-RN~ ReviewQ uestion s
1 Answer: 1
Rationale: HMG-CoA reductase inhibitors may cause rhab domyolysis, a rare but serious adverse effect. Constipation
and hemorrhoids may result from bile acid sequestrants.
Flushing or hot flash- type effeds may result from nicotinic
acid. Cognitive Level: Analysis. Nurs i ng Process: Asres!;ment. Patient Need: Physiological Integrity.
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3 Answer:4
4 Answer: J
Ratiouale: The nurse teaches the patient with a diagnosis of hyperlipidemia about lipids in the body. The nurse informs the
patient that the major storage form of fat in the body is triglycerides. Cognifh-e l.ewE: Analysis. Nursing Process: Implementation. Patient ~d: Health Promotion and Maintenance.
5 A"m-ers: I, 2
Rationale: Long-term use of lipid-lowering therapy may
cause depletion or decreased absorption of folic acid and
the fat-soluble vitamins. Decrease in potassium, iodine,
chloride. and protein is not a direct-effect of lipid-lowering
therapy. Cognitil'e Level: Application. Nursi ng Process: Implementation. Pa tient Need: Physiological Integrity.
6 Answers: 1,2,4
Rationale: Vegetables such as broccoli and carrots, most
nuts, and fish such as salmon and sardines provide soluble
fiber and are good sources of omega-3 fatty acids and coenzyme QIO. Grapefruit and grapefruit juice may inhibit the
metabolism of the statins and lead to potentially toxic levels. Cognifive l.e,eI: Application. Nursing Process: Implementation. Patient Need: Physiological Integrity.
Answers 10 Cr itical Thinking Questiolls
Photosensitivity is a major problem with atorvast~tin
(Lipitor), so the patient must take precautions such as using sunscreen, wearing sunglasses and protective clothing,and staying out of the direct Silll as much as possible.
This will probably be a lifestyle change for this patient,
and education with reinforcement is necesS<lry.
2 1bis medication has the possibility of causing esophageal
irritation, so taking the proper fluids or food with this
medication is important. Pulpy fruit such as applesauce
oouldbe used for dual purposes with this drug, because the
applesauce works for the esophageal irritation, and it also
may help prevent the constipation caused by the drug.
3 The nurse should advise this patient to seek medical advice before self-medicating--especially because this patient has diabetes, and many drugs affect hyperglycemic
~b<D
,tt
Chapter 23
I A.nswer: J
Rationale: Furosemide was prescribed as an adjunct treatment for hypertension. Blood pressure within norma! limits indicates thatlTeatment has beffi effective. Absena- of
edema, weight loss, and frequency of vo iding is ll'lated to
fluid status. Cognit io'e Le.'e/; An al ysis. Nursing Process:
Evaluation. Pat ient Need: Ph ysiological Integrity.
2 Answer: I
6 AIIsw.>r. 2
Ratiunillc Propranolol and other ~ta-blocking drugs are
used to preven t ll'f1ex tKhycard ia that may occ ur as a reo;uJt
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is not lowered too dramatically, or hypotension may (K,ur. This is an example o f a case in whim t2Q/80 mmHg is
not necessarily an ideal blood pressure readi ng. Typically,
the blood pressure is not lowered below 160 mmHg systolic. Tht' patient is reevaluated and then (often many
hours later) the blood pressure is brought clown further.
This drip is light sensitive and must renuin oovered with
foil during infusion. Once ptqXlred, the drip is stable for
only 24 hours. NitropruWiide is a cpnide by-product;
therefore, any patient On thi . drug mu! t be Illonito,cd for
cyanide toxicity.
Chapter 24
Answers to NCLEX- RNI> ReviewQ uu tioM
I Amwers: J, 4
Riltiollale: Digoxin helps increase the contractility of Ihe
heart thus increasing ca rdi ac o utput. The heart rale will decrease with the use of d igoxin . Cogni,;.'f! Level: Analysis.
Nursing Process: Evaluation. "",ient Nud: Physiological
Integrity.
812
AppooolxO
2 NISWtr: 1
This diabetic patien t needs 10 be educated about the importance of regular glucoSl' checks, bKause this medication may cause the blood suga r to vary spoooiolly.
Typically, hypoglYCl'mia is more of a problem. so the patient Deeds to be especially aware of the symptoms and
treatment of hypoglycemia. Safety should be emph.asized.
especiaUy regarding postural hypotension.
4 Answer: 1
Rationale: Digoxin and other positive inotropiC drugs increaS{' myocardial contractility, allowing the ventricles to
ejed blood more forcefully and maintaining orga n perfusion. In hean failure, blood pressure may be lower than normal o r hypotensive due 10 decreased cardiac o utput and
urinary output dKlines as renal perfusion decreases. Therapeutic l'ffeets include normalized blood pressure and urine
output. Positive inotropes exert effects on hean rate
through incrl'ases in cardi:ac output. In addition, digoxin
slows heart rate do to effeclS on the conduction 5y5tem. Posith"l' inotropes do nol have diurelic effeclS. Increased urine
output is secondary to increased reffill perfusion. Whil e
digoxin eJU'rlS l'ffects on the cardiac conduct ion system, oot
aU positive inotropes affect the conduction syStem.
Cognitive Le"d: Analysis. Nur$ ing ProcelS: Implementation. Pa';enJ Need: Physiological Integrity.
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Chapter 25
Answers to NCLEX-RN- ReviewQuest io ns
1 AnSloO'er: 2
Rationale: At the initial onset of chest pain, sublingual nitroglycerin is administl'red 10 assist in the diagnosis, and three
doses may be taken 5 minutes apart. Pain that persislS 5 to
10 minutes aftl'r the initial dose may indicate a myocardial
infarction, and the pntienl shou ld seek medienl 3s&istanee.
Cognitive uw/: Application. Nurs/llg Procell; Impl ementation. Patient Need: Ph~iologic:al lntegrity.
2 Answer:4
Roti01lole: Patil'nlS are often instructed to remove the transdermal patch for 6 to t2 hours uch day or withhold the
night-time dose of the oral medications to delay the development of tolerance. Because the oxygen demands of the
hean during sll'ep arl' diminishl'd, the patient with stable
angina experil'nces few anginal episodes during this drugfree interval. Cognitive uve/: Appli~tion. NUfl;IIg Proceu:
Impleml'ntation. Patient Need: Physiological Integrity.
5 Answers:J,1,J,4
Appendix D
Cognitive Le~'e/: Application. Nursing Process: Implementation. Pat ient Need: Physiological Integrity.
6 Answer: 2
Rationale: Erectile dysfunction drugs such as siidenafil (Viagra), vardenafil (Levitra ), and tadaIaftl (Cialis) decrease
blood pressure. \I/hen combined with nitrates, severe and
prolonged hypotension may result. Erectile dysfunction
drugs do not contain nitrates. These drugs are not recognized as useful for the treatment of anginal pain. These
drugs do not oontain nitrates and do not lead to nitrate tolerance. Cognitive Lel'el: Analysis. Nursing Process: Implementation. Patient Need: Physiological Integrity.
Chaptlu 26
Answers to NCLEX-RN'" Rev iewQuestions
1 Answer:4
Ral;Ollale: Beta blocker, d""rea.se the bodr', adrenergic
"fight-or-flight" response and may block the symptoms and
signals of hypoglycemia that a diabetic normally perceives
as the blood sugar drops. Beta blockers may inhibit
glyoogenolysis, resulting in hypoglycemia and have no effect
on the development of insulin resistance. Cognitivt w'el:
Analysis. Nursi ng Process: Implementation. Patient Need:
Physiological Integrity.
2 Answer: 1
Rationale: In the absence of ECG monitoring, the nurse would
assess the pulse for rate, regularity, quality, and volwne, noting any changes. The nurse should also teach the patient to
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monitor the pulse for rate and regubrity, before sending the
patient home. The nurse is monitoring for the therapeutic effects of antidysrhytlunic therapy. While blood pressure and
drug levcl rnay also be monitored, they do not evaluate the
therapeutic effects of the drug. Urine output may change related to the type of drug given and any effects on cardiac output, but frequent output monitoring is not indicated in
routine antidysrhythmic therapy and will not assess for therapeutic drug effects. Cognitil-e Le~-el: Analysis. Nursing
Process: Assessment. Patient Need: Physiological Integrity.
3 AlISwer: J
Ratiol/ale: Calciwn channel blockers such as verapamil
8 14
AppeoolxO
Chapter 27
Answers to NCLEX-RN" ReviewQuestions
I Amwer: 4
Rationale: Prothrombinase conwrts prothrombin to thrombin. Thrombin then converts fibrinogen to long strands of
fibrin, which provide a framework for the clot. Thrombin
and fibrin are formed only after the injury occurs. Fibrin
strands form an insoluble web over the injured area to stop
blood loss. Cognirive Lel-el: Analysis. Nursing Process: Im plementation. Patient Need: Physiological Integrity.
2 Answer: 2
Rutiu"u/e; AHlj""agul~llls du Hul ~hallg~ Ih" vi,~u,jly uf II,,,
blood. Instead, anticoagulants exert a negative charge on the
surface of the platelets, so that dwnping or aggregation of
cells is inhibited. Cognitive Lne/: Analysis. Nursing Process:
Implementation. Patient Need: Physiological Integrity.
3 Allswers: I, 2, 3, 4
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Enoxaparin is given to prevent development of ovr. Patients should be taught signs and symptoms of ovr to observe for and should contact their health care provider
immediately if these develop. Cognitive Le~-eI: Analysis.
Nursing Process; Implementation. Patient Need; Physio"
logical Integrity.
4 Answer:4
6 Answer: 2
Rationale: Antiplatelet drugs such as clopidogrel are given to
inhibit platelet aggregation and thus reduce the risk of
Ihrombus formation. Anliplatelet drugs do nol exert anti inflammatory, antipyretic, or analgesic effects. The antiplatelet and anticoagulant drugs do not prevent emboli
formation. Thrombolytics dissolw existing blood clots.
Cognitive w-e/: Analysis. Nursing Process: Implementation. Palient Need: Physiological Integrity.
Answers to Cr itical Thinkin g Questions
The nurse should question the health care provider about
this order. No patient who appears to be having a CVA
(brain attack) should have heparin until a CT scan of the
brain has been done. Approximately 20% ofCVAs are hemorrhagic; these types ofCVAs must be ruled out before
an anticoagulant is given.
2 Themajor adverse effect of a fibrinolytic drug is bleeding.
All tubes (nasogastric, Foley catheter, or endotracheal)
must be inserted, bloo;:l needs to be drawn, and IVs need
to be inserted before the medication is given. Otherwise,
the drugs may potentiate bleeding in this patient.
3 Whether the nurse gives this drug or is teaching the patient to self-administer the medication, proper placement
of the needle in the abdomen is vital. The injection must
be given at least I to 2 inches away from the umbilicus.
Major blood vessels nm close to the umbilicus, and if the
LMWH is given near one of these vessels, there is an in creased chance of bleeding into the abdomen or formation of a large (and often initially occult) hematoma in
the abdomen.
AppendlxD
Chapter28
Answers to NCLEX-RN@> ReviewQuestions
I Answers: 1,2,3
Rationale: This medication does not cure the primary disease condition; however, it helps reduce the anemia that
dramatically affects the patient's ability to function. The
hematocrit and hemoglobin levels will provide reference for
evaluating the drug's effectiveness. Cognithe Leyel; Analysis. Nursing Process: Evaluation. Parie"t Need: Physiological Integrity.
4 AnJWer: 1
Rationale: This drug increases the risk of thromboembolic
disease. The patient should be monitored for early signs of
CVA or MI. Cognlthe Level: Analysis. Nursing Process: Assessment. Pa tient Need: Safe, Effective Care Environment.
5 Answer: 2
Rationale: Filgrastim stimulates granulocytes (\'/BO;). Filgrastim does not stimulate RBC production or enhance/
replace electrolytes. Cognitil-e Levet. Application. Nursing
Prouss: Implementation. Patient Need: Physiological Integrity.
6 Answer: 1
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8 16
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4 Nlswer:J
Rationale: Anaphylactic reactions may occur with the use of
plasma protein fraction (Plasmanate). Symptoms include
periorbital edema, urticaria, wheezing, and respiratory difficulties. Cognitive Level: Analysis. Nursing Process: Assessment. Patient Need: Physiological Integrity.
5 Amwu: I
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Chapter 30
Answers to NCLEX-RN" ReviewQuestions
I Answer: 1
Rationale: Because the kidneys excrete most drugs, patients
with renal fuilure will need a significantly lower dosage of
medications that may damage the kidneys, to avoid fatal
consequences. Cognitive Le~el: Analysis. Nursing Process:
Implemenrntion. Patient Need: Physiological Integrity.
2 Answer: 1
Rationale: Potassium is a serious side effect of loop diuretics, and this is a serious concern for patients being treated
with digmin (Lanoxin). Cognithe Le~el: Analysis. Nursing
Process: Evaluation. Plltient Need: Physiological Imegrity.
3 An5'i"er:.J
Rationale: Rapid excretion of large amounts of fluid predisposes the patient to potassium deficits and is manifested by
hypotension, dizziness, cardiac dysrhythmias, and fainting.
Polydipsia is not associated with hypokalemia, but with di
abetes. Hypertension is an indication for the use of diuretics. Diarrhea can be associated with hyperkalemia.
Cognitive Le~"el: Analysis. Nursing Process: Alsessment.
Patient Need: Physiological Integrity.
4 Answer: 2
Appendix D
Chapter 31
Answers to NCLEX-RN8 ReviewQuestions
1 Allswer: 1
Rationale: Thirst is the most important regulator of fluid in~
take. Cognithe Len/: Analysis. Nursing Process: Assessment. Parienr Need: Physiological Integrity.
2 Allswer: 2
Rationale: Dextran 40, a plasma volwne expander, causes
fluid to move rapidly from the tissues to vascular spaces,
which places the patient at risk for fluid overload. Cognirile
Level: Analysis. Nursing Process: Implementation. Patient
Need: Physiological Integrity.
3 Allsl1'ers:l,4
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8 18
AppeoolxO
2 The patient may be considered dehydrated despite her ap pearance as indicated by her elevated hematocrit and hemoglobin (~hemoroncentrationn ) . Most pregnant women
present with normal or slightly decreased hemoglobin and
hematocrit levels related to the increase in intravascular
volume during pregnancy. The midwife recognizes the
need to increase the intravascular fluid compartment to
promote renal and uterine perfusion. Careful monitoring
of the patient's blood pressure, pulse, and weight should be
maintained.
3 Excessive renal fluid loss due to diuretic therapy, such as
with furosemide (La six), can contribute to fluid volume
deficits in patients taking these medications. Because
pharmacotherapy with thiazide or loop diuretics such as
furosemide is the most common cause of potassium
loss, patients taking these diuretics are usually instructed to take oral potassiwn sup plements to prevent
hypokalemi~.
Chapter 32
Answers to NCLEX-RN" ReviewQ uestions
1 Answer: 4
Rationale: Due to immune system suppression by the med
ication, infections are common. Cognitive Level: Application.
Nurs ing Process: Diagnosis. Patient Need: Physiological
Integrity.
2 Answer: 4
Rationale: Grapefruit juice increases cydosporine levels
50% to 200%, resulting in drug toxicity. Hand washing is
important to prevent infection. Renal toxicity and hypertension are adverse effects of cydosporine therapy.
Cogni tive Lnel: Analysis. Nursing PrOU5$; Assessment.
Pa tient NeeiC Physiological Integrity.
3 Answer: 2
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3 Cydosporine is a toxic medication with many serious ad verse effects. The nurse must understand that this drug
cannot be given with grapefruit juice; patients who take
this medication need their kidney function assessed regularly (not because of the kidney transplant but because
cydosporine reduces urine output ). The nurse also must
assess whether this patient is rnkingsteroids, which are of
ten given concurrently with cydosporine, as the serum
glucose needs to be monitored regularly.
Answer to Avoidin g Medicatio n Errors
Methotrelate is given for rhewnatoid arthritis in smaller doses
than when used in cancer chemotherapy. It is thought to block
AppendlxD
Answers to NCLEX-RN"
ReviewQue~tions
I Answer:]
8 19
4 Answer:4
Rationale: Excessive doses of acetaminophen or regular consumption of alcohol may increase the risk of ht'patic toxicity wht'n acetaminophen is used. Rt'nal damage, thrombotic
effects, and pulmonary damagt' are not adverse effects associated specifically with acetaminophen. Cognitive Lel'e/:
Application. Nursing Process: Assessment. Patient Need:
Physiological Integrity.
.,r: '
6 Ans ...
Rationale: Aspirin and salicylates are associated with an increased risk of Reye's syndrome in children under 18, especiaUyin the presence of viral infectioru;.Acetaminophen is not
quantifiably different than aspirin or salicylates for the treatment offever. Use of aspirin or salicylates should not increase
fever although maycause nausea or vomiting related to GI irritation but is not contraindicated in children specifically for
this reason. Cogrritil-e w-el: Application Nursing Prouss:
Implenlentation. Patient Need: Physiological InttWity.
Answers to Critical ThinkingQuestions
This patient has many potential problems related to the
use of prednisone over a sustained period. The primary
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Chapter 34
2 AIISwer: 1
820
AppeoolxD
4 Nlswer: 1, 1
Rarionale: Ciprofloxacin (Cipro) is a fluoroquinolone
antibiotic. Fluoroquinolones may be taken with food or
meals but dairy, ferrous sulfate or antacids may affect
absorption and should not be conswned at the same time
as the medic~tion is t~ken. Fluoroquinolone. h~ve been
associated with tendonitis and tendon rupture and any
Wlusual pain, especially in the heel, lower leg or calf, or
difficulty walking should be reported to the provider.
Cogni five Ln-e/: Application. Nursing Process: Application.
Pa lienf Need; Physiological Integrity.
5 Answers:l,2,J
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asa rash or hives. In severe cases,bronchospasm and cardiovascular compromise are possible. Because the drug is a
large tablet, it is permissible to break the tablet in half and
provide a large glass of water.
Chapter 35
Answers to NC LEXRN* Review Questions
I Answer: J
Rationale: Systemic antifungal drugs have little or no antibacterial activity. Auid intake should be increased with this
medication because it can affect renal function. The full
course of therapy should be completed. All intramuscuJ.1f
sites have the potential to bruise. Cognifive Level: Analysis.
Nurs ing Process: Implementation. Pa tient Need : Physiological Integrity.
2 Answer: 2
sis. Nursi"8 Process: Impleme ntation. Pulien! Netll: Phys iological Integrity.
4 Ans"'1Ir: 2
Rilrionale: Oseit3mivir (Ta miflu) and unam ivir (~ lenu)
are availab le and may preve nt the flu or if taken within
48 hours of symp toms, may limit the length of the d isease.
Immunity begins approximately 2 weeks after immuniuoon. Vaccination is recommended (or high -risk populations
and for healthy adults over 65. Ru may be highly contagious
and at-risk patients shouid not wait until symptoms begin
to seek vaccination or treatment. Cognili."t' w -r/: Applica_
tion . Nursing Proceu: Implementat ion. Patiell' Nud: Phys iologicallntegrity.
AnSh'1lr: J
RatioMle: Neurologic adverse effects may occur b ut dizzi_
Answers: I, 2
Rationale: Acyclovir ca n be renal to.tic and fluids should be
Chap ter 36
AnS1o'>'ers to NCLEX.- RN. Review Questio ns
I Answer; 2
Rationale Drug th enpy has not produced 3 curt' but has re-
Rationale: Two laboratory tests used to guIde pharmacotherapy are an absolute CD4 co unt and an HIV RNA
measurement. Clotting factor3 and a CBC do not provide
information for guiding HIV-A IDS therapy. Coglli, ive
Level: Anal ysis. Nursi"g Proc:t,,: Imple mentation. Pmie1lf
Need: Physiological Int egrit y.
3 Answer. I
Riltiorlilir. The medi cation should be take n on an empty
_tom.:ldl for m:u:imum abso rption. C"8",,;r;... L.vel, Anat y_
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Chapter37
Answers to NCLEXRN. Review Questions
I Answer: 1
un!':
2 Answer:3
woe':
4 Answer: J
Rarionnle: The nurse should monitor for blood d)'Krasias
rt$u1 tingfrom bone marrow suppression by monitoring the
eBC with differential and platelet count. Cog"iti.'Ct w'Ct':
Analysis. Nursing Process: EvaI~tion. Pat;,mt Need: Physi
ological Integrify.
S Answer. 1
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J The nurse should remain with the solution and call for
someone to bring the chemo spin kit immediately. While
waiting for lhe spill kil, the nune may cover the cont<lm
inated Ouid with paper towels ( the nune musl not touch
the solution withoul wearing protective equipment). The
nurse should clean up the spill and dispose of the waste
per hospital protocols. AI no time should the chemother
apy spill bf left unattended.
Chapter 38
Answers to NCLEXRN. ReviewQuest ions
1 Answer: J
J A"swer. J
RatUmale: Firstgeneration H,. receptor antagonists are
contraindicated in patients with a history of dysrhythmi.as
and heart failure. These mediotions can ca use vasodilation
ofvessels due to H, stimulation. These medications h.we no
relationsh.ip to wright gain or Pfptic u.lcer disease.
Cognitive Lew': Analysis. Nuni ng Proceu: Assessment.
Patient Nerd: Physiologicallnt<'gl"ity.
4 Answers:J,1,5
App<>ndlx D
Chapter 39
Answers to NCLEX-RN8 ReviewQuestions
1 Answer: 2
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823
824
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Chapter40
Answt'r's to NCLEX-RN- Rev iew Quest io ns
1 Allswer: J
Rationale: Antacids are generally oombinations of aluminum hydroxide and magnesium hydroxide. Hypermagnesemia can develop with use of ore antacids while on
renal dialysis because the kidneys are unable to excrete ex cess magnesium. Hyperkal emi a is a complicatio n of renal
failure. Hypernatremia can occur with use of antacids.
Cognitive Levt/: Analysis. NIJ"ing Proreu: Im plementation. Patient N~'ed: Physiological Integrity.
2 Answer: I
Rationale: Two or more antibiotics are used to lower the po tential for bacterial resistance and increa5l!' the ettectiveness
of therapy. Bacterial infections can recur, requiring future
treatment. Cogni,i.-e w-el: Analysis. N ursing Process: Implementation. Pillien' Need: Physiological lntegriry.
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3 Answer: 1
AppendlxD
825
should IX' taken before administering and the drug held if the
blood pressure is below 90/60 mmHg or below parameters as
ordered by the provider. The pulse will be taken along with
the blood pressure but may increase in relationship to hypoteru;ion (i.e., reflex tachycardia). Prochlorperazine does not
directly affect llUlg solUlds or temperature. Cogn itive l.el"el:
Application. Nursing Process: Implemenilltion. Pa/ient
Need: Physiological Integrity.
Answers to Crit ical Thinking Q uestio ns
A priority for the nurse is to assess the potential for dehydration. The nurse should assess the patient for possible
hypotension and tachycardia. The cause of this ongoing diarrhea needs to be investigated by the health care provider.
2 The patient needs to be informed that prochlorperuine
(Companne) is administered in its own syringe and must
not h" mixed with any other <irlle. The nil"'" m1llti notify
3 Answer: 1
Rationale: Stress is one of the major factors in developing
IBS. HelicoblKter pylori is associated with developmem of
2 Answer: 1
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ChaptQr 42
I Answer:4
Pernicious anemia results in the inability to absorb vitamin
B" d ue to the lack of intriru;ic factor in the gut. Replacem"nt
therapy must IX' administered via intramuscular injection
becaust' oral supplementation will not be absorbed. Perniciou, anemia affect.. vitamin D" absorption. Cog"i/;. ....
Le~el: Application. Nursi ng Process: Implementation.
Patient Need: Physiological Integrity.
2 Alf5wers: 1, J, 4
J AlI5wer: J
Rationale: Hypomagnesemia should be assessed. Patients aperiencing hypomagnesemia may experience general weakness, dysrhythmias, hypertension, loss of deep tendon refiexe;,
and respiratory dt'J'ression. Cognifive Level: Analysis. Nursing
Process: Assessment. Patient Need: Physiological Integrity.
826
AppeoolxO
4 NISWtr: 4
Rarionale: Alcohol is known for its ability to inhibit the absorption of thiamine and folic acid. Alcohol abuse is the
most common cause of thiamine deficiency. Cognithe
Levtl: Analysis. Nursing Process: Implementation. Patient
Nud: Physiological Inlegrity.
5 Answer: J
2 Answer: 1
Rationale: This drug may mask the signs and symptoms of
infection. Hydrocortisone is contraindicated in patients
with known infections or hypersensitivity to the drug. Skin
infections, heart failure, and hearing loss are not associated
with Ihe use of hydrocortisone. Cogni,;' ... Le,e/: Analysis.
Nursing Process: Implementation. Patient Need: Physiological Integrity.
pro~
3 Answer: 2
6 Answer:J
4 Answer: 2
Rationale: The patient may have the hormonal condition
hyperthyroidism. Symptoms of hyperthyroidism include
diarrhea, stress intolerance, and weight loss. The other disease processes are not related to the thyroid gland. Cognith...
Level: An~lysi . Nursi"g Process: Implement:ltion. Pmien'
Need: Physiological Integrity.
5 Answers: 2, 5
RatiO/lale: Because small doses of radiation will be emitted
for up to 1 week, patients should avoid close contact with
children or pregnant women after drug administration. Radioacti~ iodine is used to permanently decrease thyroid
function. Patients may experience hypothyroidism, including signs and symptoms such as general weakness, muscle
cramps, and dry skin. Ruids do not affect radiation levels.
Cognitive Lewl: Application. Nursing Process: Implementation. PMient Need: Physiological Integrity.
6 Alls"...r: 4
Rationale: Desmopressin nasal spray should be used in the
evening to mimic the body's own natural rhythms. Gently
rotating the bottle rather than shaking, storing the bottle in
room temperature conditions lllliess excessive heat is present, and spraying the drug high into the nasal cavity are all
appropriate administration techniques. Cognitive Level:
Application. Nursing Process: Implementation. Patient
Need: Physiological Integrity.
Rai1onale: Glucocorticoidscan incre3S(' the risk of pepticulcers, decrease wound healing, and increase capillary
fragility. Glucooorticoids place the patient at increased risk
for infection. The other options do not cause increased risk
for peptic ulcers, delayed wound healing, or infection.
Cognitive Level: Analysis. Nursing Process: Implementation. Patient Need: PhysioloJ!;icai InteJ!;Tity.
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Appendix D
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RatiO/wle: Humalog is a rapid-acting insulin that is administered for elevated glucose levels and should be given 0 to
IS minutes before breakfast. Hypoglycemic reactions may
occur rapidly if Humalog insulin is not supported by sufficient food intake. The medication can be mixed in one syringe. Cognitive Le~er: Application. Nursing Process:
Implementation. Pafient Need: Physiological Integrity.
3 Answer:3
828
AppeoolxO
2 Answer: 1
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cause water intoxication in patients with prolonged IV infusion of oxytocin. Cognitil-e Level: Analysis. Nursing
Process: Assessment. Patient Need: Physiological Integrity.
4 Allswers: 1,:Z
Rationale: Barriercontraception is needed only when two or
more doses are missed. Placebos are usually iron, which has
no effect on estrogen-related adverse effects. Side effects include intolerance to contact lenses, abdominal cramps, dysmenorrhea, breast fullness, headache, acne, skin rash,
hypertension, and thromboembolic disorders. Cogllitile
Level: Analysis. Nursillg Process: Implementation. Patient
Need: Ph}'!;iological Integrity.
5 AIIs..-er::Z
Rationale: Although some antibiotics and anticonvulsants
can reduce the efficacy of oral contraceptives, the most common cause of pregnancy in patients using oral contraceptives is skipping two or more doses. Cognirh-e Le~e/:
Analysis. Nursing Process: Implementation. Patient Need:
Physiological Integrity.
6 AIISIWr:
adminis~
tered in dosesof20 milliunitslminor greater. Urine outpu t decreases, and fluid retention il'l(reases. Mon
patients be-gi n a postpartum diuresis and are able 10 balance fl uid volumes relatively quickly. However, Ihe nurse
should evaluate the patient for signs of water inloxica
tion, which include drowsiness, listlesmess, h.-adache,
~nd oliguri~.
Chapter 46
An swers to NCLEX- RNe RevitwQ uestions
I AllsIi'ers:2,J
RatiOlwle: A side effect of testosterone therapy is fluid retention. Testosterone is also used to increase muscle mass and
strength. The hem~tocrit usually increases with the use of
testosterone, because it promotes the synthesis of erythropoietin. Cogn itive Le"d: Analysis. Nu ,.,in8 ProceJS: Assessment. Piltient Nud: Physiological Integrity.
2 Answer. I
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829
6 A/lJl\!erJ: I, J, 4
Rilrionale: Enlarged prostatic tissue will dt'Crease over a pe_
riod of 3 to 6 months. The drug is teratogenic and should
not be- handled by pregnant women. Blood donation should
not occur while takingfin:l.Steride because it maybe- given to
a woman. Finasteride in lowerdose:s is given under the trade
name KPropecia- for treatment of baldness. Cog"irh-e Level:
Application. Nurs;"g Process: Implementation. Altien.
Nud: Physiological Integrity.
8 30
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Chaptlr47
Answers to NCLEX RN_ Rev iew Que~tio n s
] Answer: J
Rationale: Osteomal3da, referred to as r!eke" in chi ldren , is
a disorder characterized by softening of bon es without alteratio n in basic bone structure. Classic signs o f rickets in
child ren include bowlegs and a pigoon b re4lst. Shortness of
b reath, crutch walking, and finger and toe deformities are
not associated with 05toomalacia. Cognitive wei: Analysis. N ursing Process: Assessm~nt. Patien, Nud: Physiological lntegrity.
2 Answer: 1
4 Allswers: J, 2, J
Rationale: Signs and sym pto ms of hy~rcalcemia includ e
anorexia, vomitin g, excessive thi nt, fatigue, and con fu sion.
Kidney sto nes may IXcur, and bones may fracture eas ily.
Cardiac dysrhythmias may IXcu r, because calc ium ions
influena the elICitability of all neurons. Whenever calcium
concen trations are too high, sodium permeabilityd~reases
:Kross cell membranes. This is a dangerous state, because
ner..-e conduction depends o n the proper influx of sodium
into cells. Cognitive Lew/: Analysis. Nursing ProUfJ: As
....... tn~ n t. Pat;~n t Nd: PhY3iologkallnt egr ity.
5 Answer: 2
Rationale: Sodium hyalurona te (HyalganJ is administered
by injection directly into the knee joint. This med icatio n reo
places or supplements the body's ru.tural hyaluronic acid
that deteriorated be,ause of the inflammation of osteoarthritis. AU other routes are incorrect. Cogniti,-e L"e/:
Analysis. N urs ing Process: Implementation. Pa lient Need:
Physiological Integrity.
6 Answers: 2, 1, "
Rationale: Bisphosphonates such ll5a lendrona te require the
patient to tau th e drug on an empty stomach and remain
upright for 30 minutes to J hour. Adequate serum calcium
levels should l>econfinned before starting bisphospho nates
and adequate calcium and vitam in D intake should be encouraged while on drug therapy. Any narrowi ng of the
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App<>ndb<O
2. Right drug
3. Right dose
4. Right route
5. Right time
Chapt8r48
Answers to NCLEX_RN8 ReviewQuestions
I Answer: 2
Rationale: To ensure the effectiveness of drug therapy, patients should inspect hair shafts after treatment, checking
for nits bycombing with a fine-toothed comb after the hair
is dry. This procedure must be conducted daily for at least
I week after treatment. The patient does not require isolation. Linens should be washed with hot water; bleach is not
required. Cognithe Ln-el: Analysis. Nursing Process: Implementation. Parient Need: Physiological Integrity.
2 Answers: 1,2,5
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4 AnSlwrs: 2, J, 4
Rotionale: Washing the face gently with a mild soap and using sunscreens and protection from sun exposure are part of
the care required for patients taking tretinoin. Mild dryness,
redness, and peeling skin are all possible adverse effects that
are e..""<pected but any ~evere , kin irritation or pain , hould be
reported. SWl exposure should be avoided unless specifically instructed to do so by the health care provider.
Cognitive Lele/: Application. Nursing Process: Implementation. Patienr Need: Physiological Integrity.
5 AIIS"",r: 2
Rotionale: Initial drying of the skin caused by benzoyl peroxide will help to clear acne lesions in the early stages of
treatment but it may take several weeks before full effects are
visible. One week of keratolytic therapy for acne should
demonstr:lte the begilllling of therapeutic effects. Most acne
is responsive to keratolytic therapy but may need an antibiotic included as part of the treatment plan after a full course
of the ker.ltolytic has been tried. Only in severe cases is oral
drug therapy usually considered, after other treatment op
tions have not been successful. Cognifile Level: Application.
Nursing Process: Implementation. Patielfl Need: Physiolog.
ical Integrity.
6 AlISwers: I, 2, 4
832
Apper>dl~
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Cha tllr 49
Answers to NCLEX_ RNII Rev iew Q u esti on s
I
A,nSh~r:
Rationllle: Closed_angle gl3ucoma is an acute type of gLau((Ima that is caused by stress, impact injury, or medications.
Pressure imide the anterior chambtr increases suddenly ""cause the iris is pushed over the area where the aqueous fluid
normally drains. Signs 3nd symptofll5 include intense
headaches, difficulty concentrating, bloodshot eyes, blurred
vision, and a bulging iris. ClOsed-angle glaucoma oonstitutes
an emergency. AU other options are inappropriate in this
emergency. eognitil"l! Level: Application. Nursing Prouu:
Impleme-ntation. Pa tient Need. Ph~iologicallntegrity.
2 A,/fSh'l'f: 4
taught how to check the pulse and blood pressure before administration and to notify the health care provider if l'Xtremes occur. Beta-adrenergic drugs do not affect urine
output, respiratory rate, or glucose levels. Cognitivr u''e/:
Analr-;is. N urs ing Prore$S: Implementation. Patien' Neell:
Physiological Integrity.
4 Answer:4
6 ,4"SWl"r.4
RJltronlllr. Conuctlenses should be nrnm'N before instiUing eye drops and remain out for a minimum of 15 minute
after instilling qe drops. Administering ~ drops inlo the
conjunctival sac. applying $light pressure to the Iacrinul
duct for 1 full minuu. and avoiding dirKt contatt with the
dropper tip and the~ are all appropriate IKhniques to use
when administering eye drops. Cognitive Lncl: Application. NUN;nKProceu: Implementation. Ptuil.'n( Netd: Physiologicallntegrily.
Answe rl lO Crili cal Thinking Questions
Conisporin Otic is a combination of neomycin,
polymyxin &, and I'MI hydrocormooe. The technique for
instilling this drug applie to most eardrops. Th.e nurse
nms to instruct IIw molher 10 position her daughter in
a side-lying position with the affected ear !adng up. The
mothtr nOOs to inspect the ear for the prek'n<e of
drainage or cerumen and, if present, gently remO\"e it with
a cotton-tipped applica tor. Any unusual odor ordraina~
could indicate a ruptured tympanic membrane and
should be reported to the health care provider. Nat, the
mother should be laught to straighten the mild's external
ear canal by pullins down and back on the auricle to promote distribution of Ihe medication to deeper external
ear 51rUClUTe5. Af'ttr the drops are instilled, the mother
can further promote medication distribution by gently
pressing on the tragus of the ear. The mother should be
taught to keep her daughter in a side_lying position for
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J All ophthalmic agenu should be administered in the conj unClivai $aC. The cornea is highly innervated, and direct
applic:Uion of medicatio n to the cornea can result in excessiVl' burning and stingi ng. Tke conjunctival sac normally holds one or two drops of solution. The patient
should be reminded to place pressure on the inner can_
thus of the ~ followin8 administration of the medication to prevent the medication from flOWing in to the
nasolacrimal duct. This maneuver helps prevent systemic
absorption of medication and decreases the risk of side
effects commonly :wociated with antiglaucoma agenl5.
CALCULATING DOSAGES
I. CALCULATING DOSAGE USING RATIOS
AND PROPORTIONS
A. A mno is used to express a relationship between two or
I tablet
Quantitydesired (X tablets)
Cross-multiplication gives:
2.5mgX = 20 mg X 1 tablet
sol ution/solven t
I part drug A
10 parts solution
10
Desired dose
Quantity on hand
fonnula as follow:>:
Quantity desired (X) =
Desired dose
Dose on hand X quantity on hand
."
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BSA=
Ap~IxE
835
30 X 24
3\3]
rna
BSA - "rut
.. X -"""..
hX
~re
"'"
mL = h
mL
\,00094
X J7g
mLofsolution x gtt/mL
glt
h ohdministration x 60 minfh
min
pi
"""pi
mL
mL
P7s
= h
kg x~x
min
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"'"
X - - h - X 1.0009>4 X
1,000 p;;?g
Acetylcholine primary neurotransmitter of 1M pansympathc'lic IltO'OU5 system; also present .1 somatlc neuromuscular
junctions and at sympatMk pregangllonk otrvtS
Acetyk holinestel"1lSle (AchE) enzyme thai degrades atttyldJoIjot ",ithin the 5)'1llplk deft. enhalKing effects o( the
neurotransmitter
Acidosis oondltlon of havlnS too much add In the blood;
pwnu pH below 7.3S
Arne vulgaris oondition characterized by snull inflamed
bumps that appear on the surhce oflheskin
Acquired immunodeficiency syndrome (AIDS) infection
caused by the human Immunodeficiency virus ( HIV)
Acquired resistance the capacity of a microbe to no longer be
affected by a druS folklwlnsantJ . lnfectllo1:' plurmacotherapy
Adton potential eledrtc.al dianvs in the membraot of a musdeor nel'l'l' cell due 10 changes In membranepermeabiUty
activatoo chaK(t;olI short_term treatment (withln60 minures) after a patient has ingested a threatening amount of carbon-based
polson; molecules adhere to adlvated charcoal and minimize or
prevent poisons from IbsorpUon
Ad ive im munity resl5tanct resulting (rom a previous uposure
to an antigen
Mu te gouty . rthriti. condition In ",,1Ilch uric add crystals
alXumulate in the ;oint$ of the big toes. ankles. wrists. finsen.
knees. or elbows, result'", In red. swollen. or inflamed tissue
Acute radi alton syndrome Ufe-lhreiltenJng symptoms resultIng from acutt exposure 10 Ionlling radbtlon, Induding nausea,
vomltins. severe kukoptnb., thrombocy1openla, anft1lla, and
.""".
'"
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_.
.-
Gto.... y
"'1"'=
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837
'm=
Bipolar disorder syndrome characterized by ~reme and opposite moods, snch as euphoria and depression
838
Glo".ry
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bowel
Cations positively charged Ions
CD4 receptor protein that accepts HIV and aUowsentryoftbe
virus into the T4lymphocyte
Ce ntral nervous system (CNS) division of the rltI'vousS)'Stem
consLsting of the brain and spinal oord
Chemical na me otrid chnnkal nomenditure wed for naming
drugs established by the International Union of Purt and Applied O!emiWy (IUPAC)
<llemoreceptor trigger zone{CfZ) location In the cerebral COfrex ",hid!. sends sensory signals to the vomiting center
Chemoreaptors nerves located in the aortic arch and carotid
sinus tnat sense~hanges in oxygen content, pH, or c~rbon dlox
ide levels in the blood
Chemotherapydrug treatment of Clncet'
Ch ief ceDs cells 10Clted in the mucosa of the stomach that se
crete pepsinogen, an inactive form of the enzyme pepsin that
chemically breaks down proteins
Cholecalciferol vitamin D, formed in the skin by exposure to
ultraviolet light
Cholinergic relating to nerves tholt release acetylcholine
Chronic bronchitis recurrent disease of the lungs character.
ized byexcess mucus production, Inflammation, and coughing
Chronic obstructive pulmonary diSf'ue (co rD) generic
term used to descrihe several pulmonary condItions characterized by cough, muws production, and Imp.1lred g.as
exchange
Oinical invmigation second stage of drug testlll8 that Involves
clinical phase trials
Qinia l phase trials testing of iii IICW drug In selected patients
Oonk spa5l1l multiple, IOlpidly rtpe;lttd mUSQllar
contractions
Oosed-angle glaucoma :tCUte glaucoma that Is caused by decreased outflow of aqueous humor from the anterior dnmber
Ootting factors substances contributing to the process of
blood hemostasis
Coagulatio n pJ'()('l5ofblood dotting
Coagulati on cascade complex series of steps by wflkh blood
-''''''
g!.lIld (blackhead)
Complement ~ ..,ri... of proteins Involved In thenonspeclfk dl'_
fense of the body that promote antigen destructIon
Complementiilry and alternative Dledici ne (CA M) treat
ments that consider the heahhofthe whole person and promote
disease prevention
Complementary and alternative thenlpi es treatments oonsidered outside the rea1m of conventional Wes\o..'1'n medicine
Compliance taking a medication In the manner prescribed by
the health care provider, or, in the case of over-th~-rounter
(arc) ~ foUowing the instructions on the label
GIoss y
LibraryPirate
839
"de
Dyslipidemia abnormal (excess or deficient) level of lipopro teins in the blood
Dysrhytlunia abnormality in cardiac rhythm
Dysthymic disorder less I''(ere type of mood disorder that may
prevent a person from feeling well or functioning normally
Dystonia severe muscle spasms, particubrly of the back, ne.::k,
tongue, and face; characterized by abnormal tension starting in
one area of the body and progressing to other areas
Eclampsia pregnancy-induced hypertensive disorder
Ectopic focu s pacemaker cardiac tissue outside the normal
cardiac conduction pathway that generates action potent~1ls
840
Glo....y
Eczema abo called aroplc dtrmmlrlr, ~ skin disorder with unexplained symptoms of in flammation, Itching. ~nd scallng
Efficacy the ability of a drug to produce a desired respomje
Electrocardiog ram (OCG) devke that reoords the electrical activity of the heart
Electroro nvulsh,,, therapy (ECI) treatment wed for serious
and life threatening mood disorders In patients who are UIU't'sponsh-e 10 pharmacothenpy
Electroencephalos,n m (HG) dJ.asoostk test that records
bnin"'";lu.'Slhrough electrodes auachlto the scalp
Elect ro lytes dlalt'd substance5 [n the blood such as sodium,
poIaMiwn, calcium, chloride, all<! pOOspha~
Embolus blood clot carried in the bloodstre~m
embr)Vnk period period oflife from 3 to S weeks poslmnct'p,,,"
Emesis mmiting
Emet ic drug used to induct mmiting
Emelic pote ntial usually applied to antlnooplastlc ~gents; degree to which an agenl is likely to trigger the vomiting center in
the medulla, resulting in nausea and vomiting
Emetogenic potcntial the aapaclty of a chemotherapeutic drug
to cause vomiting
Ilmphysem a terminal lung disease characterized by permanent
dilation of the alvroll
Endogenous opioids chemicals produced naturally within the
body that decrease or eliminate pain: they closely resemble the
actions of morphine
Endometriosis presence of endometrial tissue In nonuterine
locations such u the pelvis aoo ovaries; a common cause of in fertility
Enteral nutrition nutrients supplied orally or by f-ting mbe
Ent eral route administration of drugs onlIy, and through nasogastrk or gastrostomy tubes
Entericcoated referring to tablets tmt m"", a hard, waxy coating designed 10 dissol\-e in the alkaline environment of the ~
intestine
Enterohepatic recirculation recytUng of dross ~nd other substances bythedrrubtion ofblle throush the Intestine and liver
Enzym e induct ion process in which a drug changes the func~
tion of the hepatic microsomal enzymes and Increases mmbolic
activity in the liver
Epilepsy disorder of the CNS dlar~!zed by sekures andJor
wn\'u1sions
Ergocalciferol activated form ofvlumin D
ErgOliterol lipid substance in fungal reII membranes
Erythema rednessassoc:iated with skin Irritation
Erythrocyti c stage phase In maL1r1a during ...mlch Infected red
blood ct'Hs rupture, releasing mero~,()ltes and causing fever and
chills
Erythropoietin hormone secr~'1ed by the kidney that regulates
the processofred blood ct'U formation, or erythropoiesis
esophageal reflux baddlow of stomach contents into the esoph .g~
LibraryPirate
Q,...
Glosmy
CNS
ganglionic synapse the juncture between two multipolar neurons located outside of the (.tntral nervous system (CNS), when'
uon terminals from the first neuron make oontact with cell bodw..and P.'<f............ nf' .... .<KI'M1od """mn
gastric lavage and Ispiration oourse of treatment (within 60
minutes) after the patient has In~ a potentially life-threatening amount of polson: this Is performed by washing out the
stonuch with Slerile water or a saltwater solution followed by removal of the Huid or l1'Illt'd substaoces
Gastroesophageal nnuJ( distll~ (GERD) rtgurgitation of
Slotmch contents into the esophagus
General anesthesia med!ca1 produre Ihal produces UIKOll!iCiousnessand Iossof 5erIsation throughout the entire body
Generalized a nxiely di so rder (GAD) difficult-tn-control.
excessive aru:il'ly that lasts 6 months or mon, focuses on a v_
ariety of life events, and Interferes wIth oormal day-to-day
fun(\ions
Generalized seizures .sel~ures that trol\'l throughout the entire
brain
Generic name nonproprll'lary ",1me of a drug assigned by the
government
Genetic polymorphism changes In enl)'llle structure and
function due to mutation of the encoding gene
Gi1ucoma oondition that is charaderized by optic neuropathy
with graduallos.sof peripheral vision and usually accompanied
by imreased inlraocular pressure
Glycoprotein Il blllla enzyme that binds fibrinogen and von
Willebrand's factor 10 begin plalelet aggregation and blood coagulalion
Goal any ob;ect or ~Ive that the patient o r nurse seeks to atuin o r achieve
Gonadotropin- releasing hornlOoe hormone secreted by
the hypoIhaiamUSlhat stimulates the socretion of follide-stimulating hormone ( FSH ) and lutdnlz.ing honnone (LH )
Gout metabolic disorder (har.w:terlled by the accumulation of
uric acid in 1M bloodstream or joint cavities
Graded dose respon~ rdatlonshlp between and measurement
of the pJtierll's response obIalned at different doses of a drug
Gram negative bacteria b;w;:terla tt\:J.t do not retain a purple
stain because lhey h:ive an outer envelope
Gram positive bacteria bac\t..'tla that stain purp~ because they
h:ive nO OUler I'Ill\'lope
Graves' disease syndrome caused by hypersecretion of thyroid
homlOne
Growth fraction th~ r:Jtlo of the number of replicating (.tlls to
resting cells in a mmor
H +, K+ -ATPase en:cyme responsible for pumping acid onto the
mucosal surfa(.t of the slonulCh
HI rKeptor sile located on smooth mU!iCle (.tlls In the brondiial
tree and blood vessels thall5Stlm\~3ted byhlstamine to produce
bronchodilalion and vasodllatlon
Hr receptor antagoni $1 drug that Inhibits the effects of histamineal its receplOrs in the Gllract
Hallucination St't'ing. hearing. or feeling something that is not
""
LibraryPirate
641
,,"',
842
Glo".ry
le~
above 5 mEq/L
LibraryPirate
""'
m='"
GIoss.ry
LibraryPirate
843
=1
Myoclonic seizure seizure characterized by brief, sudden contradiolts of a group of muscles
Myxedema condition caused by insuffiCient secretion of thyroid
hormone
Nadir lowest values of erythrocyte, leukocyte, and platelet
counts caused by chemotherapy
Narcotic natural or synthetic drug related to morphine; nl.1y be
used as a broader legal term referring to hallucinogens, eNS
stimulants, marijuana, and other illegal drugs
844
Cilo"''Y
LibraryPirate
"",,
GIoss y
body
Pharmacologic classification melhoo for organizing drugs on
the basis of their mechanism of action
Pharmacology the study of medicines; the discipline pertaining
to how drugs improw or maintain health
Pharmacopoeia medical reference indicat ing standards of drug
purity, strength, and directions for synthesis
Phobia fearful feeling attached to situations or obje<:ts such as
snakes, spiders, crowds, or heights
Phosphodie sterase enzyme in muscle cells that deaves phosphodiester bonds; its inhibition increases myocard~11 contractility
Phospholipid type of lipid that contains two fatty acids, a phosphate group, and a chemical backbone of glycerol
LibraryPirate
845
do"
Plasminogen protein that prewnts fibrin clot formation; precursor of plasnlin
Polarized condition in which tht' inside of a cell is more negatively dJarged than the oUl.'lide of the ~U
Polyene antifungal class containing anlphotericin B and
nystatin
Polypharmacy the taking of multiple drugs concurrently
Positive symptoms in schiwphrenia, symptoms that add to
IIOrmal behavior, including hallucinations, delusions, and a disorganized thought or speech pattern
postganglionic neuron autollOmic nervt' aftt'r the gans!ionk
synapse transmitting impulses to the target tissue
Postmarketing surveillance evaluation of a new drug after it
has been approval. and used in large numbers of patients
Postpartum depression occurring aftt'r childbirth
Post-traumatic stress disorder type of amiety that develops in
response to reeq>eriencing a previous lift' e'.,ent that was psychologically traumatic
Potassium ion channel pathway in a plasma membrane
through which potassium ions enter and leaw
Potency the strength of a drug at a specified concentmtion
or dose
Preclinical investigation procedure implemented after a drug
has been licensed for public use, designed to provide information on use and on occurrence of sideetfects
pregllnglionic neuron autonomic nerve before the ganglionic
synapse carrying inlpulses from the spinal cord
preimplantation period period of life from I to 2 weeks postconception
Preload degree of stretch of the cardiac muscle fibers just before
they contract
Preschool child child from 3 to 5 years of age
primary-progressive MS one of the four recognized form~ of
Multiple Sclerosis named for gradual advance of the disease
from onset and with no superimposed reillpses (new or r...urfacingsymptoms) and remissions (periods of recovery)
PRN order medication is administered as required by the patient's condition (L:ltin: pro re nata)
protltrombilla5e
Proton pump inhibitor drug that inhibits the enzyme H~ , K ~ .
ATPase
Prototype drug wellunderstood model drug with which other
drugs in a pharmacologic class may be compared
Protozoa single-celled animal
Provitamin inactive chemical that is converted to a vitamin in
thebody
Pruritu s itching associated with dry,scalyskin
P50ralen drug used along with phototherapy for the treatment
of psoriasis and other severe skin disorders
Psoriasis chronic disorder characterized by red patches of skin
covered with flaky, silver colored scales
P~chedelic substance that alters peKeption and reality
Psychological dependence intense craving for a drug that
drives people to continue drug abuse
P!.yulU"""ial u.".;r;u..; a 1'''''Mln', ~y,.hutul\k"l U.,v.,[up",.,n( in
the context of one'ssocial environment
psychotic depression expression of intensely negative mood
shifts and WlUSUal behaviors involving hallucinations., delusions,
disorganized speech patterns., or loss of conrnct with reality
Purine building block of DNA and RNA, either adenine or
guanine
Purkinje fibers electrical conduction pathway leading from the
bundle branches to aU portions of the ventricles
Reabsorption movement of filtered substances from the kidney
tubule back into the blood
Rebound congestion adverse effect of intranasal decongestants;
prolonged use ClIlISes hypersecretion of mucus and mlrsening
nasal congestion once the drug effects wear ofT
Rebound insomnia increased sleeplessness that occurs when
long-tenn antianxiety or hypnotic medica tion is discontinued
Receptor the structural component of a cell to which a drug
binds in a dose-related mannt'f, to produce a response
Recommended Dietary Allowance (RDA ) amount of vitamin
or mineral needed e:lCh d~ to 3void 3 deficiency in ~ he:llthy
adult
Red-man syndrome rash on the upper body caused by certain
anti-infe.;:tives
Reflextachycardia temporary increase in heart rate that occurs
when blood pressUJ'l' falls
LibraryPirate
"'~
PRN
Salicylates the chemical family to which aspirin belongs
Salicylism poisoning due to aspirin and aspirin-like drugs
Sarcoma cancer of connective tissue such as bone, muscle, or
cartilage
Sca bicide drug that kWsscabies mites
Scheduled drug in the United States, a term describing a drug
placed into one of five categories based on its potential for misuseorabuse
Schizoaffective disorder psychosis with symptoms of both
schizophrenia and mood disorders
SchizophR'nia psychosis characterized by abnormal thoughts
and thought processes, withdrawal from other people and the
outside environment, and apparent preoccupation with ont"s
own mental state
School-age child child from 6to ]2 years of age
Scurvy deficiency of vitamin C
Glomry
1&47
fillb!... cause
Multiple Sclerosis named for gr.lduaJ advan of the dlsea.sr; superimJXN'd relap5t'S (new or resurfacingS)'nlploms) and remissions (periods of recovery) may occur, but they tend to tail off
o>'<'rtime
Se<:ret ion in the kidney, IT'IO\'etl'Ient of substances from tht'
blood into the tubule after filtntion hasocrurred
Sedati ve substance that depresses the CNS to cause drowsiness
....
"'Sedati ve-h yp notic drug with the ability to produce a calming effect at lower doses and to induce sleep at higher doses
Seiz ure symptom of epilepsy charaClerlzro by abnormal neuronal discharges within the br.lln
Selective estroge n receptor modulator (S ERM ) drug that
produces an action Simi lar 10 estrogen In body tissues; used for
the treatmrnt of osteoporosis In postmenopausal women
Selective serotonin reuJlt ake inhibitor (SSRI) drug that selectively inhibits the reuptake of serotonin Into nerYe terminals;
used mostly for depression
Septic shock type of shock u used by se~e infeaion In the
bloodstream
Serotoni n synd rome 5d o( signs and symptoms as.soctiltOO
with o>t'rmedicatio n with antidepressants thatlndudes altered
mental status, fe>t'r. sweating, and bck of II'lllSCIliM
coordination
Shock condition in which there is Inadequate blood flow to meet
the body's metabolic needs
Short s ta tu~ height below the fifth percentile for aPt and gender,or mo~ thall two st~dard deviations below the mean (average) for age and gender
Sho rt -tu m o r ~h.iIiond insomnia lnJb\l!ty to sleep that is
often attributed to stress uused by a heal, Ufenyle or the inability to re;o"'e day-ta-day conflicts withln t he homeor work-
pbu
Silm t angina ITl}'OC3rd iaJ ischemia that occurs In the absenceof
1"'"
Single order medication th~t Is to be 81>'<'n only once, and at a
(jmo:, .u"h a. ~ p'''''per.ll ..... uHkJ
Sinoatrial (SA) node pacemaker ofthe heart IOOi ted in thewall
of the right atrium that controls the basic heart rate
Sinus rhythm numberofbe~ts per minu te normallygenerated
by the SA node
Situation al aru:ictyanxiety e..~p..'1 ienced by prople faced with a
stressful environment
Sleep d e bt lack of sleep
Social a nxiety fe~r of crowds
Sodium ion cha nn~ l pathway In a plasma m~mbr.lne through
which sodium ions enter aoo !e<l\'e
~I""-ifi~
LibraryPirate
848
Glomry
LibraryPirate
by Myc:oll<lcterium tuberculosis
Tumo r abnormal
~we]]j ng
o r mass
"TYPe 1 di abetes metabolic disease characterl~d by hyperglycemia caused by a Ia.:kof secretion of insulin by the pancreas
Type 2 diabetes chronic metabolic disease caused by insufficient
secretion of insulin by the pancreas, and a 13d of sensitivity of
insulin receptors
Tyramine form of the amino acid tyrosine that is found in foods
~uch as cheese, beer, wine, and yeast products
Ulcerative colitis inflammatory bowel disease of the colon
Undernutrition lack of adequate nutrition to meet the meta bolic demands of the body
Unstable angina sewre angina that ocrurs frequently and that
is not relieved by rest
Urinalysis diagnostic test that examines urine for the presence
of blood celli., proteins, pH, specific gravity, Rtones, glucose, and
microorganisms
GIos, y
LibraryPirate
1149
A
AAPMC (~ntibiol:it~KIt"tro
pscudO .... mbnl\OllS toliIU), 494
aN"",i 5301
aNtatept.742.
abbreviations:
toan>id.20~871
In
p~ancy.64
atebutolol:
actioll5 and uscs.I36.
for an8ina ~r>d myocardial
inf~rdion. 343.
for dyYhyt/lmlas, 36(h
effecu durln8 bmutf<lin8, 67.
for bypc:rtension, 315.
/It;(01L Su PerindoprU
aCorIamin ophrn . 4721
aclions and wes, 472.
'"
LibraryPirate
.en""
aCftylcysteine, 123
""(WI.
Indn
addiction, 14, I().I , SAo 11110 SubslaD<C' abu ...
AddiJon's dlsnst, 659" 671
adtfovir, >II, 542,
admobypopllysis, 651
tI.d~noscan. SAo i\dtnoiinc
ad~nosin~,
360" 366
drll&' clmintd IS
clopklosr~L Sn Clopidogrd
pnl$uarcl, 379,
tioclopkliM, 349, 379,. 3110
rung,
runclion,667,670f
production, 65J1f, 6721
gluclXOetlcoids. 670, Sa..Jso
hormon~
GlUcocomCOlI
gonarirxortiroids. 667
mln ..... loroftkolds.610
adrtnal mWulb. 130
Adrenalin. SAo Epin.orhrino
ad""n'''aic, 130
AIJ'HA_.
BFrA_.
AC1'OBid Sn Runl!Olid~
591
a~rosol,
affinity. 'W
In,
S Bln'A-ADltENnGIC~[m
1);1-35.
p.>til:nt and familywucation,
1);1-35.
planning: p;ltltnt pll and cxptctod
outtoma, 134,
po!<ntlal nursing diagnoKl, 134,
ADRI'.NIR(lIC ANTAGONISTS (SYMl'AlHOll'TICS):
ANTloGONI5T5
LibraryPirate
akohoI.buw:
adverw heoltb ~fkcu, 108
chronic panc""alitis and, 635, 6J5.
vitamin B, ddkioncy and, 641
wilhdtaWll symplOms, 106., ]08
Aldacwld~, J02~ 42]
Ald<lClOnc. S Spironolacton.o
aidalnrkln. 4541, 563
Aldom~t. See Methyldopa
aldosterone, 310, 423, 670
aldosterone antagonist. 329, 423. Sot ~I...
Silironolacto lle
aldoSlerone reuptor bloi:kc:r. SN Epler~no.,.
a1emt'pt, 7621, 763
ilkmlurumab, 5631. 564
Ilmdroruole.717t
IIttions ;md IlKS, 737.
administration alens. 717.
a.MtK effects. 736t, 7371
intoractlons.137.
ovtrd_ trt.t .... nt. 737.
pharmacokinetics. 737.
rOlneand adult do .., 736t
Ale .... Sot Naprw.:n sodium
Alfenta. Sa AJknlanilltydrochloride
a1ftntanll hydrochloride, 151~ 252,
N. s... Interferon alfa-nl
a1l'mosin, 125,
tl.lf~ron
A]imta, SuPomet",Ied
;tlblin~ phos['h;ota .. (ALP), 737
........
325, J26f
,,,,.,
a~.on .. t dJabd....
ADltl'.NIJl(;lCAGONlm (SYMPATHOMlMFJICS):
""'-
impicmentat ion
evaluation of outcome crimi>, 13'h
Inte/'Vt'ntionund rationales, 138-39.
p;ltimt and family education, 138-l9r
]>bnnlng: pilliont p;oaIs and apted
outco......s. 138.
poltntlal nursingdi;ognoses, 137.
A&gn.\!at. Sn Tiroliban
busulfan. 5551
carboplatin.555,
dsplatln,555,
dacarbazino, 555,
ni"~n mlUto.rd.
chlorambucil, 555.
cyclop/>osphamide, Sn
Cyclopho.phamide
ntrarnustillO,555.
albmduo". S22~513
Alboma. Sn Albenduole
Albuminn. Sot Nonnal .. rum albumin
Albu~dn. Sot Norm;ol .... um allUmin
albuteroJ:
actlonund uses. 1321
In anaphylaxis, 413
for uthma, 593, 5941
aklomelalOne, 160,
alC<)hol:
fm.ldfu:ts.6.!i,
mtUboIbm, 108
ph)'!'loIoak and psyci>ologic riJrcu,
'''-'
dru8' classified
agonlSl, SO
Ifosf..mido,555.
mrcillordhamin.o, 555.
melphalan,5551
nlttOlOl.U:oas
cumusti ne, 553, 555,
lomustln~. 5~5,
Slrq)torocin, 555.
ox:aiipl.1in, 555,
procarbazine, 555,
tomozolomide, 555,
thiot~55S1
t06~
15 1
852
Index
All.sra. Sa I'rxof.nadin.
Allrr.st. SN Napharolin.
allrr~n. 413. 574
all"gk "aclion. 18
all"8ic rhiniti 574
pathoph)"'iolosY. 574, 574/
pharmacotherapy
H, -recqltor antagoni.t .. SN
H,- RECEYroR t.NTMiQNJm
intranasal glucocortkoid .. SN
[mv.NASAL GWCOCOJmOOIDS
theraprotk approach. 574- 75
AWu,," ",a.UIn.
Se~G..,.lk
no.
All'1L\.-ADRENI1tCICANrAGONlSTI
(SYMPATHOLYTIC'l):
LibraryPirate
138-39r
patirnt and farnUy C"ducation.
138-39.
planning: patirnt goals and explI
outa>mr lJ6,
7251.7M
hypertrn.ion. 315. 315.
mh.ni.m.of action. JOI/
Nursing I'ro< ... Focu .. 316-18.
0 ..erview.I36.136.
Alphagan. See Brimonidin.
AIJ'HA- GWCOIIfI\.!E INHIBITORS:
Index
360,.
amitriptylin~:
abllS<'. I1Q.-II
ad,.r .... fflS.67 ~ 198,. 199
drug. daSllif",d as
D- and L-.1mphetamin~ racomil:
mixtur 198,
dextroamphetamine. Sa
Datroamphotamin.
m.thamphotamin~. 11Q.-II. 198,
toxicity.ign 106,
for w.ight I",,>, 634
withdrawal S)1Ilptom . IOCt
Amphot. Sa Amphot. ricin B
am photericin B, 509,
action, and uses, >09,
administration al. m. 509,
adyer .. ~fflS. 508t. 509,
interactions. 509t
pharnlarokinotics.509,
pharnlacothorapy with. 509
rout~ and adult do ... 50s,
ampicillin. 484. 484,
amyl nitrit~. 343,
amyloid plaque 263. 265f
aml"trophic lat.ral .duo.i>, 256t
LibraryPirate
ddinfion. no
nonopioid
au:aminophen. See Acotaminoph en
comtaUy-acting
donidine. Sa ehnidin.
"an"dol, 228t
nonsteroidal anti-inflammatory
drugs, See NON;"fEROID.u
~.NTI - INFLAMMAroRY
DltUGS
(NSAlDs)
opioid. Set OPIOlD (NUaJTIC)
}.l.AIJ3ESICS
853
implem~ntation
int~""ntions
and rationales,
720---21,
patient and family tducation,
720---21,
planning: patient goal. and ~t~d
outcom .... nOt
pot.ntial nursing diagno ... s, 720t
production. 667
route and adult do .... 561~ 717t
Android. Se< Methyltestosterone
Antin~. Se. Succi nylc holine
anemia:
cau .... 397
cla.. iflcation, 398. 398,
d~flnition. 397
iron-d.flckncy.400
pernicious. 399
pharmacotherapy
folic add. Set Folic add/folal<
iron. See lIloN s.un
vitamin Bu. Set Vitamin Bu
in renal failur~,420,
anesthetics:
g~neral.
o,"",,,-iew, 343,
ranolazin., J41
th.rapeutic approadt.. 341
.ymptom . :J.40
Angiomax. See Bivalirudin
angiot.nsin [[.310
ANGIQTIN,lN [[ lECll'IOR BLOCKERS
(ARB.):
8 54
Index
(ARB.), (conI,)
impl~m~ntation
int~rv.ntion'
and ralionales,
313- ]4.
patimt and family iucation,
313- 14.
pl.nning: patient goal. and exp<'<tOO
out.ornc~ 3131
pot.ntial nursing diag no .. ~ 3] 2.
for .~cific condition.
h~arl failu"" 327, 3281
hyp<rten.ion, 3021, 3] I
angiot~n.in -conycrling~nzym ~ (ACE), 310
ANGJOTI:NSIN- OONHRnNG ENrrME (ACE)
lNHmrrolS:
trandoiapril, 3] I,
~thnk/racial considerations,)]],
mrchani.m. of action, 30 I/. 3lO,
326,327f
Nursing Proce.. Foeu.
" ..... ment, 3\2.
....aloation of oulcome criteria, 3]41
implementation
int~".. ntion. and ralionale.,
313- 14,
patimt and family iucation,
313- 14.
planning: patimt goal. and exp<'<ted
oUlcomes, 3131
pot.ntial nursing diagno ..s, 3] 2,
for .~cific condition.
hearl failu"" 326-27, 3281
hyp<rtm,ion, 3021, 3lO- 11
m)'X3rdial infarclion, 351
anidulafungin, 508~ 5] 2
anions,436, 436,
anomia , 609
anorexiant., 631
sibutramin~. s.., Sibulr.. mine
An<aid. Me Flurbiprofen
Antabu",. Sa Di.mlfiram
ANl"MJDS,6]S
adv~".. dfects,
6] 5,
drug. da .. ifii as
aluminum hydroxide. Su Alumi num
h ydroxid e
calcium carbonat~. Sn Calcium
carbonate
caldum caroonate wi th magnesium
hydroxide,6lSI
LibraryPirate
magaldral<,6]5.
magnesium hydroxid~, 615,
magn~sium hydroxide and aluminum
hydroxid~, 6]5,
on
mechanism. of action, 6]Of
pharmacotherapy with, 615
route and adult do ..., 615,
antagonism, 482
anta80niS!,5(I
anteriorchambtr, 767, 767f
ANT!:2101 PmJITAlY AG!Nn:
""",
""",
drugs classified a.
folic acid. See Folk acidJfolat~
iron. Me [ION SAm
vitamin Bu. s.., Vitamin B"
Nursing Proa.. Foeu,
assessment, 401,
evalualion of outcome.riteria, 402.
impl. m entation
int.rvemionsand rationaks, 4021
patient and farnilyeducation, 4021
planning: patient goals and expected
outcom",402,
potential nursing diagnoses, 4011
ANI"!Il.\.CJU1MS:
cr",",s
aUc'lO'to,483
drugs cla .. ified as
aminoglywsides. See AM1NO(;l=!DES
aztreonam,4951
carba~n<1ll'
erta~n.m,
49SI, 499
imipen~m -cilastatin,
495., 499
4951, 499
c~ph.l",porin'. ~ CI'PHAW'POI1NS
chIoJ";lrnphcni,ol, 49SI,776
dindamydn, 494, 495,
c)'dic lipo~l'tid
daptomydn, 4951, 499
Uuoroquinolon ... Su
FWOIOQUINOWNE>
fosfomycin, 4951
mero~nem,
utolid~,
Index
diph~nhrdramin .
Sn
Diph~nh rdramin e
gl)alpyrrolau, 143.
homatropine, 774,
ipratropium bromide.Sn
Iprdtropium bromide
oxybmynin, 143,
procydidine hydrochloride, 260.
prol"'nthdin~, 143.
scopolamine. Su Scopolamin~
tiotropium, 594. 594.
trihexyphenidyl hydrochJorid~,
143~ 260.
tropicamide.774.
mechani,m.of action, 143, 259, 259f
Nursingl'roct .. Focu.
aN.I!mcnt, 145.
impltmentation
"""1,, ion "f OIl'CO..,.,. crit~ri 14Ii'
intervention. and rationales, 146.
pationt and fantilyffiucation, 146.
planning: I"'ti~nt soal. and ""ptcted
outcom... 145.
poI<ntial nursing diagn.,..,,;, 145.
for spKifk conditions
asthma
mechani.m. of action, 594
route and adult doses, 594.
overview, 143-44
Parkinoon. disea..,
mechani.m. of action. 259, 259f
route and adult do",.. 260.
ANTIOOAG\JlJJm:
fondapariIllu, 374,
heparin. Su He porin
low-molecular-weight heparin . Sn
Low-MOLE.C1Jl.AJI- W<:IGIIT fill'ARIN!
warfarin. &e Warfarin
home cue conoid.ration .. l7j,
m~chani'm. of action, 373, 373., 374f
Nursing Pr~ss Focu,
asses,ment, 376-77.
evaluation of outcome crit~ria, 379.
impltmentation
int ervention, and rational ...
377- 79.
pationl and famiiyffiucation,
377- 79.
planning: pati~nt soal,and expected
outcom... 377.
potential nursin8 diagno..", 376-77.
phamlacotherapy with, 373-75
for spifk condition,
m)'OCardial in farction, 349
thromoo..mbolic di .. a .., 373-74, 374.
Amm<:PRE~
cia"""
LibraryPirate
.. lecti'... serotonin
reupt~
inhibitors.
INIIIBITORS
and ralionaki,
191- 93.
[>'It i~nt
J\.IzlIeimtr'sdiseaSl'.266
anxiety syn-tptom" r~st.l ..'ne... and
d~p",,,ion, 154-56, 155.
d~pr=ion, 184, ISSf, 186.
suicid. risk and, 183-84
ANI1DIARIlHF.AI.I:
""
855
ANI11JYS11ITIHMla:
Amiding Medication Errors, >65,
d as,ifkation, 359, 359.
drug. dassififfi a.
ad~no,in~. 360 . 366
beta-adrenergic anla8Ollist . Sn also
BEfA-ADIINEIGIC ANTAGONISTS
"',
th~raptutic
approach, 359
N uning Process Focu,
a .... 'm.nt, 361,
evaluation of oulcomecriteria, 363,
implenl~ntation
856
Index
ANI1EMITIcs, ("'~t.)
~u<ocortkoids
dcxam~thason~.
See Da:amdhason~
Sa
MethylprinisoJon e
neurokinin r=ptor antaeonist
ap"'pilant, 629, 630.
phenothiazines
chara{tnislks,629
metoclopramid.,63Ot
perph~nazin . See P.rpb.nazin~
prochlorp<razin . See
Prochlorperazin..
prom<thazine. See Promtthazin.
... rolonin r=plOr antaeonists
characteristics,629
dolasmon, 629, 6301
grani>tuon,629.6JOt
ondan ... tron,629, 63(I.
palono.. tron, 629, 6JO.
Nursing Process Focus
a",ssllYnt.632.
n'alnation of outCOmt criteria, 633t
implem.ntation
intt rvtnlions and rdlionaks. 632- 331
patiem and family alucation, 632- 33t
planning: patient goal. and expe<ti
outcom ... 632.
pol.ntial nursing diagnost .. 632.
route and adult do .... 630.
antifibrinolyti". Sa HJ:MOITAllc.1
antill.tul.m,615
m~thylprednisolone.
ANI1FUNGAI.I:
azol
adver ... ~ffts, 513., 51 4
drug. dassifoed as
butoconazolo,5[3.
dotrimazok. See Clotrimazol.
.conazole, 513.
floconazol . See Fluconazole
itraconazole, 20., 512, 513., 514
ketoconarole. Su Kttoconazol.
miconazol ., 5131. 752
oxiconazol., 513.
.. rtaconazok,513t
sukonazol., 5Ut
t.n:onazol.,513t
tioc:onazol., 513.
""ri""n.ml~.<;ll.
m~chanisms
of action, 512
pharmacotb.rapy with, 512
rout. and adull do .... 513t
tchinocandins
anidulafungin, 508~ 512
caspofungin. 508~ 512
m""hani,m, of aclion, 508
Nursin g Process Focu,
""SSllYnt, 510.
n'alnation of outcome criteria, 512t
implem.ntation
int.rwntion.and rationale.. 511}...12t
patient and family iucation,
510-12.
LibraryPirate
adver...ffts, 770t
drugs dassifl.-.:l as
alpha,-ad",ntrgk agoni'"
apradonidine, 769, 770.
brimonidin~, 769, 770t
btta-ad",nergic antagonist.
bttaxolol, 770.
cartrolol, 136t
l.~bunolol, 770.
m<tipranolol,770.
timoloJ. Sn TImolol
carbonic anhydra .. inhibitors
acetazolamide. 770., 773
brinzolamid.,770t
dorrolamide, 77Ot, 773
m.thazolamidl', 770t
miotic. (choline~ic agonist.)
c.. ..ruchol.77fl.
hothiophal. iodide, 770t
physoslismin~, 770.
pilocarpin., 140., 770 . 771
osmotic diureti"
isosorbid.,773
mannitol,773
urea, 773
prostaglandin.
birnatoprost. 769, 770.
latanoprost. Su Lllanoprost
tra'>Uprost, 769, 770.
unoprostone, 769
5fII1pathomimetk.
dipiwfrin. 770 . 773
abc Hyperl<nsion
drug. classifil'd as
adrtn.~ic agonist . Su ALPHA
ANI1HYFI:RTI:NSIVO. Set
ADRENERGIC AGONlm
adn:n.~k
antaeonists. Su
AI.PW.- ADRENIJtGICANTAGONlSTI;
BETA- ADRENERGIC ANTAGONlm
diuretics. Sa DIUREI1c.1
vasodilalors. See VA>ODlL\.TORS
m""hanisms of action. 30 If
.. I""tion of, 301 - 3
Index
ANTI- INrncrlVl'.l:
defmition.479
for H. pylori. 616-17
hOST fa<lor., 483
mrchanisms of action. 480. 481!
prophylacTic u"". 482
.tl~C1iOll. 482-83
topical. 752
""Tili, ium. See Ph)"Ostigmine
Am1M.UARlAl.S:
advcr .. effects.516t
drug.dassif.. d a s
arTrnleTh.r/lumrlamrine. 516. 5 16.
atmaql1One a nd proguanil. 516t
chloroquine. See Chloroqu in.
hydroxychloroquine. See
H ydroxrcl!loroquin.
mefloquine.516.
primaquin 516t
pyrimethamine. 516.
quinine.516t
pharmacoTh.rapy with. SIS
rouT~ and adult d05oO., 516.
Am1MEI"AIIOUfES:
S'" ANTI-INI'EC11HS
Am1MIGRAINE DilIJ(;S:
LibraryPirate
rrovatriptan.233t
naraTripTan.233.
rizatriptan. 233,
SUmaTripTan. See Snmatript an
zolm itriptan.233.
Nursing Proce.s Focus
a ... ssm~m. 235.
impl.menTation
evaluaTion of ouTcom.
erilfria. H6t
inT.....,ntion. and rationale ..
235-361
pati.nT and family educaTion.
235-361
planning: pati.nt goal,and.xp<ekd
outcome .. 235t
pottntial nur.;ing diagno~. 235.
route and adult doses. Z:J:Jt
AntiminTh. See PyranTd
AN11NEOPlASTICS:
altrffilmine.563.
anTimeTaboliTes. 555,. See alsa
Ir.NnM!."fAIlOLrITS
""rinostat. 563,
,.,l.dronk add. 563t
8fO">"1h fra<lion and
of. 551
II1tchanisms of ~C1ion. 550[, 551
nadir.55Z
,11<,"'''
857
"'-'"
<XpC"I:T~d
outcom .,565r
potential nursing diagno .... 565.
in older adulT .. 562t
pharmacotherapy proTocols and
str~lfgi... 552
ANI1PlATE!.f AGINI"S:
"rou
am.....fffCt .. 521t
drug,dassifieda,
antimalarial See ANT!MALARlAL'i
iodoquinol. 521.
metronidazole. See McIronid azol.
nifurTimox.521.
paromom)'dn . 490. 490<. 521.
penTamidine. 52 It
sodium stibop,lnconalf. 521t
Tinidazol 517. 521.
Nursing Pnx.., Focu,
a,..,smem.51St
evaluation of outcome criteria. 520.
implementation
inte""ntionsand raTionale.. 51 8-20.
paTknT and familyeduCiltion.
518-20.
planning: paTimTgoals and <XpC"I:lfd
outcome .. 51St
pot.ntial nursing diagno ..., 518t
roUle and adulT do .... 521
858
Index
ANIlPSYUlOfIa:
ad"""", dfem, 206-7, 1fJ7I, 472-73
drugs dassifii as
atypical.ntipsychOlks, Sa IirYPlCAl
ANIlPSYUlOTIQ
convemional (typical) amipsydx>lics
nonpbono!hiazlnes, ~
NONPHINOTI[L\.ZINL'i
Nursing Process Focus, 209-111
phenolltiazine. See PHINOTI[L\.ZINL'i
dopamine sysum stabiliz. .... 216
m""hanism.of actio n , 1fJ5/
ANIl!"fREI1(S, 471
drugs dassifii as
acetaminoph.n. Sa Autam ino phen
aspirin. Sa Aspirin
ibuprofen. See Ibu profen
Nursing Process Focus
a ...ssmem, 4731
....aluation of oUico,"" criteria, 475,
implem.nlation
ime"",ntions and ration.les. 474-75,
patiem and family iucation,
474-75,
planning: patient goals and expeo:ted
oUicomes, 473,
pol.ntial nu ... ing diagno ..s, 473t
therapeutic approach, 472
ANIllf."I1tOVlv.u;:
ad"e"", df.cts, 557t
complianu, pSl"'ho.ocial issues, 533,
drugs dassifii as
fusion and in~ra .. inhibito ...
enfuYinide,5JOt, 531
maraviroc, 5JOt
raltegravir, 5JOt, 531
nonnucleoside ",,,,,r.. transcript ...
inhibito ...
delavirdine,5JO,
efavirtnz. Six Efovi",,1Z
etravirine,5JOt
n .... irapin., 5JO" 533
nucleoside and nucleotide ""..,...
transcripta .. inhibilo ...
ahac.vir,530,
didanosine, 5301, 537
emlricitabin., 530" 538
lamivudine, 530" 538
st.vudin.,5JO,
t.nofovir, 5JOt, 531. 538
zid,wudine. Sa Zidovudine
prot.a.. inhibitors
adv.,... .ffects, 530,
.mprm.vir,530t
alazan.vir,5JOt
darun.vir, 5JO" 533
fosamprtnaYir, 5JO,
herb--drug int.ractions, lOOt
indinavir,5JOt
lopinavir/ritonavir. Sa l.opinavir/
ritonavir
mechanisms of action, 537
nelfinavir,5JO,
LibraryPirate
""'-=
,,,I>..
""'=
quinine, 274,
"'-'"
"'-'"
planning: patient goals and expected
palient and family education,
outcomes, 668,
pot. ntial nursing diagno ...., 668,
pharmacotherapy with, 663-64
route and adult doses, 663,
ANTITUBI1IC1Jl.O\IS DRUGS:
Index
rifabutin, SOOt
rifampln, SOOr
rifaP<'ntiM,SOOr
Rif.tn,SOOr
second-liM ~ts
amibcln, SOOt
;unlOOAllcylk add, 500<
al'rwmydn,5OOt
c;prot1oadn. S(r O proflo:u dn
",doKrin(,500.
ethionamide, SOO,
kanamydn, SOO,
ot\oxacln, SOO,
Itrq>toot)'Cln, SOO,
Nuuin8 Proc..,s Focus
a ....$Sment. S02.
nalualion of Olltmmt crituia, 5031
impkrntntatlon
intf/fV(ntionf and ntlonalts, 502- 3.
p;ltitnt and family aiuration, 502- 3,
P.... nln8: p;ltknt piland apraed
outcomes. S02.
potential nI.trsin8 di"8"ootJ, S02,
pharmacotherapy with, 499-501
roul~ and adult doscs. SOO.
AmITUMOR ANTIBIOTICS:
583
drugldal,lfla!u
bmzonotale.583.
,<><kitW:. SuCodcine
dcxtromcthorph;ln. SN
Ocxtrome toorphan
hydrocodont . Su Hydroco<bne
for hcrpcsvirusct
Nunln~ Procns Fc-<:uJ, 543--45,
srSl.mlc aae nu
acyclovir. S Acr<lovi r
ad .... rKdJu.S38'
cidofovi 538.
famclclovlr. S381
foKarnct.538.
pnddovlr.538t
LibraryPirate
au_'S,.
dolin.ion.1SO
incKkn.151.
intolT.nia .nd, 152
modd for Slr(S$ managcmtnl, 152f
nonph.armacologic managtm~nt.
151-52. 1521
Nursb8l'rocull'oru.
'!S<lIm(nl.161,
lmplemmtatlon
I ..~lu;ulonof outwn.. cri .... ia, 1631
In ........ ntions and roulonal..,
16~3,
162-'3t
plalnlng: p;ltlmt goal.and apccted
outromn, 162.
potent~ nul'$lngdillK .......... 1611
pcrfotman, ISO
pharmacotherapy
anlidtpr(SS<ll\I .. 155t. ~ al."
ANT10tl'Af>SANTS
""""'~~
nolbctuOdllupitW:. nonbubitunltc
CNS dtprmants, 160 16LScealw
NotlWlzoolAZll'lNE,
/(ONMUITUlATE CNS Dll'Rr5SAI'mi
859
appdhe,6JI
appdh~ MlI'P,,"saRt.. Sa AIIoruiam.
apraclonidint. 769, 770.
421
Ap~tnlitW:. SN
Hydralazin .
>proNrbital, 159,
>protlnln, 386.
!.ptlvus. STlprallitvir
aP'TT (."ivat(d panial thromboplastin
llmcl,J71
AquaMEI'HYTON. ~Vitamin K
Aquasol .... ~t Vita min A
Aqu:.osol E. Stt Vitamin E
Aquat(nson. St~ MethyclothW:ide
aqueous humor, 767
Arduan. S Pipuronium
A~ia.
S P~midron.t.
.rformolerol.594,
.rg~lrob.n,
3n. 3nl
S Cbnlin.
oaJicyIa~
anlaitW:. U2.
ASA. S A~pirin
AAOOl. Su Mt$alamine
ASAP order, 20
ASCilrd. Sa Pyrantd
A5Olr;, I"",bricutd~ 522
ascorbic Kid. SttVilamin C
Ascorbic.p. SttVilamin C
AKndln. SAmox:apin~
Asians:
depression treatment ronsid .... tion"
182.
pain managnnont,220.
prop ... noInl stnsitivity, 363,
AIlmMX. Su MortW:1;uotW:
860
Index
LibraryPirate
AlOlone. Sa Triamdnolone
.tomoutine, 198t. 201
.tonk .. izUK. 168,
.Iopied.mtatiti.. 759. See ulw Lkrmatili.
a lorvastalin, 2901
anions and u ..s. 290,
administration alert.. 29(},
adverst df.d .. 287., 290,
int~/';IClion" 290r
pharmacokin~tiC5, 290t
route and adull do", 287.
.to"'quone and proguanil, 516t
.tracurium.27&
.trial fibrillation, 355. 355.
.trial flutter, 355,
atrial tachycardia. 355.
atrioventrkular (AV) bundle.}>6
atrio.... ntrkular (AV) node, 356
A!ripla,531
Atromid-S. Sa Clofibrate
Atropa beUadonna, 143
Atropair. S Atropin e
A!ro-ITn. S Atropine
atropine.l44r
actions and U>fl. 143r, 144. IHI
administration aI.",.. 144,
adyer.. eff..:t .. 144,
int~ractiO/ls, 144,
Oy.rdo.. "eatment. 144,
pharmacokinetics. 144,
for .o;pedtk condilions
as cydOJlI~gk, 774,
a. nerYe .g~nt.ntidot~, 120
.tropine ",Ifate. ] 23.
IUropi",,!. Sa Atropine
At"""'nt. Sa I pratropiutll bromide
Atryn. See Antithrombin
an~m ion defic il-hypera<:tivity disor<kr
(ADHD):
characteristia.197
Nu"ing Process Focus
assessment, 199t
impl~m.ntation
"",
interYention nd rational .. ,
199--200,
patient .nd familyC'ducation ,
199--100.
ATYPICAL ANTIDEPll.SM.NTS:
"""'
Indn
A.zaS3n. S A.zatbioprin~
azathioprine.457. 458,. 625. 742,
az<lak add. 756. 756,
azela'tin~.575,. 774
AIelex. Su ARlak acid
azithromydn. 489. 489t. 501
Azmacort. Set Triamcinolon~
azol~. 512
azole antifungals. Su AN11FUNGAll. Jzoll'S
azoos~rmia. 718
Awr.302,
AZT. & . Zidovudi nc
azt=nam.495,
Azulfidine. &~ Sulfas;o lazine
Bc"[I.447
bacampkmin.484t
badlli. 479
Badl/u. anth,ads. 118. 480,. Snalso
Anthrax
Bacm.... Calm.n~-G""rin (BCG) vacdn~.
454; 457
bacitracin ointm~nt. 752
badofcn. 271. 272,
bact".mia. 480t
bacteria. 479. 479,. 480t. & a/so .pocifit:
LibraryPirate
short acting
~ntobarbital
sodium. See
Pentobarbital sodium
sc<obarbital. &. Secobarbital
grndk polymorph isms affecting
melabolism. 81,
h",b-<irug int~ ractions, tOO,
rout~ and adult doses. 159t
for specific conditions
as adjuncts to anesthesia
amobarbital. Set Amobarbital
butabarbital sodium. 252,
~ntobarbital sodium. Sn
Pentobarbital sodium
sc<obarbital. See Secobarbital
as intravenous ane"b.tk.
etomidate.251,
methohexital sodium. 251t
propofol. 25 I,
sedation and insomnia. 158- 59. 159,
seizures
mechanisms of action. 170--71. 170{
route and adult do..s. 171,
toxidty signs, l06t
uses. ISS-59
witlxlrawal symptoms, 106,
baror<ptors, 298
basal ganglia. 204. 205f
basal m~tabolic ratc. 661
ba.. lin. data. 55
bask supportivecar~. 121
basUiximab, 457. 458t
BayRab. &e Rabies immune globulin
BayRho-D. See Rho(D) immune
globulin
BayTn &e Tetanus immun~ globulin
BCG (Badll.... CaJllYlte. Gutrin ) vacdne.
454,.457
beclo mdhaso ne.6oot
actions and u .... 600t
administration alerts. 600,
ad,..,rst effects. 596,. 600t
inhaled. 596,
intranasal.580t
pbarmacokinetics, 60(1,
rout e and adult do ... 596,
Becona... Su Beclomnh aso ne
Becona.. AQ. See Bcc1omdh ..o ne
bchavionl (ohon. term) insomnia. 153
belladonna. 143
Benadryl. &. Diphenhydramin e
BenadrylAll~IVICold caplet .. 576,
benaz.cpril. 311,
lxuda,uu>!iue.555.
bendrollumethiazide.422<
Brn~mid. See Probenecid
Benicar. See Olm~sartan mtdoxomil
BcnicarHC.J02t
benign. 549,
benign pro5latk hypcrtropby (BPH):
inddence.7lfu
natural th~rapy with saw palm.tto,
726.
116 1
abuse. 107
ad.... "".ffw .. 157t.17I'
drugs dassifiN a.
alprazolam.157,
chlordiazepoxide. 157,
donaz.cpam. See Clonazcpam
d.)ra zepat~. 157t. 171,
diazepam. See Di azepam
eslazolam.157t
halazepam.157.157,
loT"dzcpam. See Lorazepam
midazolam . lOt. 157.251'
oxazepam.157t
quaz.cpam.157t
trnlaz.cpam.157,
triazolam.157.
fall risk in older adults and. 158t
herb--drug interaction .. 100,
Lifespan Considerations. 158t
rouuand adult do ..s. 157,. 171,
for specific condition.
Alzheim",, di",. ... 266
anxiotyand insomnia
advcnedJ.cts,157,
mechanism. of action. 157
Nursing Process !'oeu.. 161-ii3,
rout~andadultdo .... 157t
a, intra""nous an~sthffics, 251 ,
.. izurrs
ad,m.< <rre~( .. t 7 t,
indication .. 172
route and adult do .... 171t
as skdetal musele reluant. 271. 272,
structure. 157
toxicity sign .. 106,
uses, 157
withdr....... l symptom .. 106,
b.nzonatal<. 583. 583,
benzoyl ~ro:xide. 756. 756t
862
Index
rn.nztropine, 2631
actions and uses, 259f, 2631
administration alerts, 263,
ad"""" dfects, 2601, 2631
interactions, 263,
"""rdo,", treatment, 263,
pharmacokinetks, 2631
route .nd adult dOlle, 2601
u .... 143'
bepridil,343,
beractant, 601 1
beriberi, 643
bela ",lis, 679/
beta (II) r"""ptors, 13]" ]33
IlE.'JA- ADRND.GIC.-.GONISTS
(SYMPATIlOMIMIITIO) :
770t
drugs dassifii as
a1buterol. See Albuterol
arformottrol,594,
betaxolol,770t
<lil'iV<'frin, 77Ot, 771
dobutamine. Su Dobulamine
dopamine. See Dopamin.
epinephrinf. Set Epi tlq>h rin.
formoterol, 132" 594,
iooprolerenol. Su looprolfltnol
1"""lbuterol, 593, 594,
metaproterenol, 132t
metaraminol, ] 32,
norepin ephrine. Su Nor<pin<ph rine
pirbuterol acelale, 593, 594t
pseudoephedrine. Su PotUdoephedrine
ritodrine, 132t, 709
salm<'lerol. See Salmeterol
terbutalin . Su Terbutaline
genetic polymorphism' affecring
metabolism, glt
for specific conditions
asthma. Su BJONCIlODlIATOI.I
glaucoma, 769, 770t
htarl failure, 335
o""rv;",w, 132t, ]33
'ocolyti<, 709
IlfA- ADREND.CICANI"AGONI!IT.I
(SYMPATHOLYfIO ) :
LibraryPirate
medunisms of acrion
in . ngina. 342/
in dysrhythmias. 358f, 363
in htarl failure. 327f, 33]
in hyperten,ion. 30]/
o....rview. 136
Nunin8 Process Pocus
assessment, 137t
implementation
<Valuation of outcome criteria. ]39,
inter""ntion. and rational ... 138--39,
patient and family education.
138-39,
pla~nin8: patient go.ls and exp:li
outcome 138,
potential nursing diagnoses, 137,
for specific ronditions
an~ina and mj<>cardial infarction.
:;43.343,
anxiety. 160,
dy.llhythmias
>c'ion., lSMi lS9,
Btnar. Sa Tositumomab
BGTD (Biologics and Gen<'lic n..rapies
Direclor.>I. ).9
Biaxin. SlY Clarithrom)"in
bicalutamiJe,56],
BkiUin. See Prnkillin G benzathine
BiCNU. See Carmustine
BiDil, 311~328t
BIGI1ANID~
~I>"
IMMUNOSJ!MIJLANP.i
IndH
738- 39t
patknt and familyroucation,
738- 39,
planning: patient soal. and nptcted
outcomes,738t
potential nursing diagnos<s. 738t
for Paget', dis<as<, 737
rome and adult dos< .. 736,
bivalirudin, 374, 374,
black cohosh, 961, 97t, 98/, 704t
BI~uomyCf' Jermatitidis, 507t
blastomycosis, 507 t
bl.-eding time, 372,
bleomycin, 550f, 557t
blister/..."icant ag<nts, bioterrorism, 121,
Blocadren. &e Ii molo l
blood ag<nts, biotcrrorism, 121 ,
blood dots, 371
blood doping, 391 t
blood pressure. &e ~Isc Hypet"tension
faaors affecting, 298, 29S/
physiological regulation, 298-99,
299f, 300/
BI.OOD PROD\.TCn:
'n><>
LibraryPirate
osteoporosis. Sa Osteoporosis
Paget'. diseas<. 737
hone resorption, 732
Bonine. Set; Meclizinc
Boni.... See lbandronate
homters, 448
Borrclia /;urgdo.fori, 480t
hone701nib,563,
bolaniC;lJ, 9S. See Rlw Hcrbalthcrapkl
Botox. Su Botulinum toxin type "
botulinun toxin typ< ", 273, 274f,
.74t,277t
botulin~m tm:in typ< B, 273, 274f, 274,
Bowman'. capsul~, 418
BPH . Su Benign prostatk hy~nrophy
bradyki .... ia,256
br.ldykinin,4651
brand-norm drugs:
marhting and promotional
sptnding, 14t
vs. g<nerk" U - 14
Bra...dle. Sec Urofollitropin
b",aluhrough bltroins, 699t, 706
b",ast -f<ling:
eli."t teaching about drull therapy
ciurinS,68
drug therapy considerations, 66--68, 67/
drugs with ad...,r", effects during, 67 t
oxytocin function in, 709/
B"'thine. Se Terbutalin~
Brevibloc. Se Esmolol
Brevital. Se Methohoxital sodium
brimonidine, 769, 770,
brinzolamide,770,
broad-'ptrum antibiotia, 482. See ~Isc
!&NTIMCIl'.R1A1S
bromoc,iptino:
ad...,r.. dfects during breast-feeding, 67,
for female infmility, 712, 712,
for p...kinson'. di .... S<. 257, 258,
for Iy:>< 2 diabttes mellitus, 689
bromph,niramine,575,
bronchioles, 590
BlONCIlODl!A.TOJtS:
anticlolinugics
ad"""", effects, 594~ 595
ipn'mpi"m hmmid~ . .'in
663
.. lmetero!' Se Salmcterol
terbutaline. Se Terbutaline
mechanism. of action, 590
mcthylx.onthino,
ad....".s< effed" 594r, 595
aminophyUine, 594,. 595
pharrnacotbtrapy with, 595
route and adult do ..s, 594,
theophylline, 1001, 5941, ,95
Nursing Proces. Focu.
a ..... ment, 597 t
....aluation of outcome criteria, 599t
implem~ntation
butenaflne.51 4 ,
Butiso!' S Butabarbital
butoconazole,5Ut
buto'1'hanol tartrat~, nIl, 222,
Byetta. See wnatide
c
C fIDers, 220
ea++. Se Calcium
CABG (coronary artery bypass graft)
surgery, 340
C!J) (coronary .nuydi",.",), 339, 341,
eafe'll"t. Se Ergotamine with caff";ne
caffeine,SI" III
864
Index
Calan. Sa "erapamU
Calcidrine Syrup, 584,
calcifediol. 732.732f
Cakikrol. Sa Ergocalciferol
Calcijtx. See Co.lcitriol
calcineurin. 457
CALaNFUJllN INHIBITORS:
con..
Mm
ph~iology.
732- 33
calcium acetate. 420,. 647t
calcium carbon.te:
.s.nt.cid.615,
for cakium ddkient:y disorders.
647,.734,
for ,""nal failu,"". 420.
calcium carbonate wit h magnesium
hj<lroxide. 615,
CALaUM DlANNEL BWCKa5 (CCBs):
.d,..,.... dfects, 307,. 343~ 360,
drugs d.ssifii as
amlodipine. 307,
I>epridU.343,
devidipin 319
diltia7.f1ll. See Diltia,.,m
felodipine. 307,
i,radipine.307,
nicardipine. J07t 319. 343,
nifiipin . Sa Nifedipil1e
nirnodipine.233,
nisoldipine.307,
verapamU. See "<"'pamil
mechani,ms of action
in angina. 342[, 347
in dysrhythmia .. 358i 365
in hypenension. lOli 307
Nursing Proc.ss Foeus
as ..ssment. J09,
evaluation of outCOIl1< criteria. 311 t
LibraryPirate
implementation
interventions and rationales.
310-11,
patient and farnUyeducation .
310-11.
planning: patient goals and expti
outcomes. 310t
potential nursing diagnoses, J09,
for ipC"dfK ronditions
angina and myocardial infan:tion. 343.
343,.347
dysrhythmias
action. and indications, 359,
ad",r .. dfects, 36(].
mechanism. of action. 358f
rout. and adult do .... 36(1,
therapeutic approach. 365
hypertension
roule and adult do ..... 307,
theraprutic approach. 307
migraine. 233,
calcium dtloride.436,. 647t. 734,
calcium citrate. 647t. 734,
calcium EDTA. IB,
calcium gluconate. 6471. 7.J.4t
calcium ion channels, 358. 358f
calcium lactate. 647,
calcium phosphate tribasic. 647.
COIleium poly<arhophil. 622r
CAI.CIUM SAlIS, 734t
actions and u ..s. 734,
administration alerts, 7.J.4r
adVM"S< dfect .. 647,. 734,
drugs classified as
calcium acetate. 420,. 647t
cakium carbonale . .se" Calcium
carbonate
cakium carbonate with magn~sium
hydroxide. 615t
calcium chloride. 436r. 647,. 7.l4,
cakium citrate. 647,. 734t
cakium gluconate . .sreG!lcium
gluconat~
drugsclassifi.d ..
irinotecan.559. 559,
topotan. Ssw. 559. 559,.
pharmacoth.rapywith.559--60
OImpwth,,",,,,,,mmata, 559
Canada:
drug approV"~1 and regulation process.
9.9,
regul,niom mlri'ting drugs of ~b\l&t.
15. 1St
Canadian Food and Drug.""t . 9. 15
canal ofs<hl.mm. 768. 768f
ca""er:
agmts associated with increa.. d risk
of. 549,
cau..,. 54&-49. 548,
(haracteriSlics.548
incidence. 548,
lifestyle changes for pre",mion. 549
metastasi .. 548. 548f
natural therapy with ..lenium for
prevc-ntion.549,
pharmacolherapy. Set AN"nNEOPlAIno
sur&o'ry.550
candesartan. 311t. 327
Candida albiraM" 507,
c.ndid ...... 507,
cannabinoid . Sa
Marijuana
characteristics. 108-9
drugs dassified as
dronabinol. 629. 630,
nabilone. 629. 630t
o.M""hi. "'tiva, lOS. s.., ~I", Marijuana
Capamll Sulfat~. Sa Capreomycin
capitabine.555t
Capoten. Sa Captoprll
C.pozide. 30lt
capreomycin. 5((),
cap.. icin.741
o.psi<llm "MMum. Sa Cayenne
capsid. 527
"I>"
capsul~s:
CAM!'fOTIlEC1NS:
characteristics. 559
adver .. dtects.425,
Index
drug. dassifled a.
a~lazolamid~. Sa Acetazolamid~
brinzolamidc.770,
dorwlamide. 770,. 773
m~thazolamid~. 425 770,
forglaueoma. 770 773
for r~nal faUur 424. 425,
carboplatin.555'
carboprost trom~thamin~, 703~ 704,
708.708.
cardnogm 548-49. 549,
carcinoma, 548. 549,
Cardene. s.... Nkardipin~
cardiac drcompensation. 326
CAJtDIAC GLlC()l;IDES:
adyer ...ffts. 328,
drugs dassiftcd as
digoxin. Sa Digoxin
f",h~~ r1 f:oi1",~. n~,. H()
nursing consid.ration,
client t.aching. 336
m~chani'm.of action. 327f
cardiac output. 298.199 325
cardiac ",mod.ling. 326
{3rd~nk ~hock. 41lS. 407.
cardiotonic druss. Sa INOTIOPIC AGENn;
cardi<w.rsiou.357
Cardium. Su DUti . um
Cardura. Sa Douro,in
Cardura XL Sn Dou..lo,in
Carimun. NF. Su Intravenous immune
globulin
carisoprodol. 272.
carmustin 553.555'
carnitin~. for hean failu",. 335,
carot.nes,64 1
caneolol.I36.
Cania XT. Sa Dilti az.m
Camol. Sa Carttolol
carve<laol. 136~ 315 328.
cascara "8rada bark:
druS int. raction,
atropin 144.
hydrocortioon 673.
phenytoin. 175,
standardization. 97,
05... './6.
Ca"",,651
Casoda. Sa Bicalutamid.
ca'pofungin.508.
ca"oroi!.622t
Cataflam. Sa Dielof.nac
Catapre . s.... donidin.
catecholamines. no
cathartic, 621
catheter ablation. 357
cation 436. 436.
ear..rjt. Sa Alpro.<tadil
ca~nne. 273.
CBER (Center for Biologks Evaluation aud
R.... n:h ).5
a::B,. See CAlCIUM rnANNEL IlI.OCUti
a::N U. Su Lomustinc
LibraryPirate
cocaine. Sa Cocaine
m~thylphcnidat~. Sa
M~ h ylph~nidate
crphalexin.487t
CIl'HAlOSPORlNf>:
.m....
ce fotrtan. 487.
cefm:itin.487.
cdprozil. 487.
ce furoxime.487.
characteristics. 487
third-generation
cddinir. 487.
cdditorrn.487t
crfiximr.487t
cefopcrazone. 487.
fotaxirn~. St. Cd otaxim.
crfpodoxim 487.
ccftazidim~. 487,
crRibutrn. 4871
crftizoJ:irnr.487t
<rftriamn~. 487t
characteristic 487
pharmacotherapy with. 485. 487
route and adult do .... 487.
cephradin~.487.
c=bralpalsy. 27It
G:rebyx. Su Fo'ph.nytoin
certolirumab 1'<"801.625. 742.
cerum.n.776
cerumen <often ..... 776
C.rvidil. Sa Dinoproston~
Ctsam.t. Sa Nabilon.
C.tarnid~. Sa Sulfawamid~
cetirizine.575.
,"'rorcli>: acetat 7l2.
C.trotid~. Sa C~rordix ac~tate
cetuximab, 563 564f
crvilllC"lin. HCI. 140t
CFSAN (Center for Food Safetyand
Applied Nutrition). 5
dt.ag.u' di ....... 521 ,
charnomile.158~ 174 212.
Chrm ... Sa Suaimer
chrmical nam~. 13-1 4
chemoprophylaxi .. 482
chemoreceptor triggrrzonr (crz). 628
'hrmon:ceptors, 298
chrmotherapy.549. Sa ~b"
ANrrnwPlASTIcs
865
866
Index
of ibuprokn and
in, 472t
dia~tes in, psychos<xiaI and cultural
impact, 682.
drug idrnini,tration d1a1knga, 191,
59,90.
drug administration guiddines
adoleK~nt. , 71 - 72
pr."hool child, 70
ochool-aS" child, 70
school-agt child"n, 7If
toddl .... , 69-70
dysJipid~mias in, 286t
Gw,dja infection., 5BI
HN inf~ction, 5>8t
medication errors in, 90~ 91.
ophthalmic drug administration, 7751
pain exprossion and pelUption, 2231
para.itic infections, 523.
"";zur~ <1iologies, 1671
a(~taminoph~n
U""',
LibraryPirate
chlorpropamide,6871
chlorprothixtne, 209.
chlorthalidone, ,l.()3~ 422, 422.
Chlor-Trimeton, Sn Chlorpheniraminr
Chlor-Trim<1011 Allergy~nS"stant
tabl<1s.576.
chlorwxazone, 2721
chokinglvomiling3gents, bioterrori.m, 121.
chokcalciferol, 732, 732f, 7341
cholera.ll6t
cholestuol:
abnormal 1"",,1.. !ire Lipid disorders
biosynthesis and =rrtion, 287, 2Uf
di<1ary restriction, 21'.6
functions, 283
laboraloryvalues, 285, 2861
in lipoprotein., 283, 21!Sf
t)'\J'ts, 283, 285f
chole.terol absorption inhibilors, Sa
Ezetimi~
galantamine hydrobromide,
] 4 0~ 264,
nrostigmine, ]39, loWl
physo.ligmin~, 139, [40., 770t
pyridostigmine, 139, t4O,
riva'tigmin~, [40., 264, 264.
tacrine, ]401, 264, 264t
mechani.m, of action, 139
MIOTICS (ANTIGUUCOMA DR\JG\)
drugs classified a.
carbachol, 770.
ochothiophatc iodid~, 7701
physostigmine, 770.
pilocarpine, 770 . 771
712t,718t
chromium,649t
chronic bronchitis, 601
chronic obstructive pulmonary di"""",
(CDPD) :
char-"cteristie&,600
pharmacotherapy, 601 - 2
chronk pain, 219
(hymt, 620
Cialis, See Tadalafil
cideoonide, 580., 5961
ddopirm: olaminc, 5[41
ddofoYir,538.
ciliary body, 767
(ilO'lawl, 379~ 380
cim~tidin.,6]2, 6]2., 635
Cirnza, Sn CertoJizumab ~go[
cinacalC<1, 736t, 739
dnnamates, 763
Cinobac, SN- Cinoxadn
dnOLldn.4921
Cipro. Sa Ciproflordcil1
CiproDex, Sa CiproOoxacin;
Daameth.",ne
ciprofloncin, 493.
action. and u ..., 4931
adminbtration alerts, 493.
ad""r"" rlfects, 492~ 493.
int eractions, 493,
pharmacokin<1ics, 493.
route and adult do"".4921
for "piflc conditions
~nth"'n'
1]9,49t
ear infections, 776, 776f
tu~n:ulosis. SOOt
drcadian rhythm,663.
cirmo,is, [08, 108.
ci.,lracurium, 278.
cisplatin, 555.
dtalopranl, [55., IS6t. 266
Cilanest, Se. Prilocaine
Citr""al, Sa Cakium dtrat~
CitruL Sn MothylUulose
CK ("ratine kina",, ), 3491
a - , SN- Chloride
d.dribine, 555.
Index
575" 576
aeodn. Su Clindamydn
aeocin-T. See aindamydn
d~vidipine, 307, 319
Qcyipra;. SIT Qevidipin(
dient teaching. See Patient and famUy
Nucation
aim.ra. Se. Estradiol
aindaMax. See Clindamycin
dindamydn,494, 495" 7561
dinical inve;tigation, in drug developm.nt,
6- 7,7f
c~nkal phaSl' trials, in drug dt\tlopment, 6-7
ainorU. Sn Sulindac
aoar. Sre Clofarabine
dobetasol, 7601
docortolone,7f1J,
dofarabin~. SS4, SSS,
dofibrate, 287~ 291
aomid. Sn Clomipb.n.
domiphene, 712, 7121, 71!
domipramine, ISS,
donaupam:
ad"crse effect., IS7t. 272,
a. muscle ",launt, 272,
for .. izuros, 171,
clonic "",.m, 271
donidin.:
action, and uses, 132,
interaction" 187" 198,
for 5Jlifk condition,
ADHD,200
hyperte05ion, 315,
pain management, HM. H':I
dopidogrel, 380,
actions and uses, 349, 3&0,
administration alerts, 380,
adyerse effects, 3791. 380,
interaction',3&01
o""rdo .. trratment, 3801
pharmacokinelic., 3&0,
rout~ and adult do ... 3791
doraupau, 157., 171/
dosed-angle gla\l<:Oma, 768, 768f
Clo>,rid;~m bolli/inurn, 273
C/m,ridium dijJirik, 4971
dotrimazole:
actiOll' and use .. 5 12, 51 5, 752
adversedJecls, SUI
rout~ and adult do .. , 5 DI
clotting disorders, 371 - 73, 37lr. 372.
clotting factors, 370
d""" oil, 2421
doxacUlin, 484. 4841
aonpen. Sn Cloxa.cUlin
dozapine, 212, 2 13,
aozaril. Su a02.apine
CNS. Su Contra! nervous sysum
coagulation, 370
LibraryPirate
867
ANI"JC(W:;\JUNfI; AN1U'lATElEf
AGEIITI; HEMOSTATICS;
THROMllOlTIlCS
OOLl.OIDI,
'n>"
5% albumin, 4361
dextran 40. Sre [)alran 40
dextran 70, 408, 4031, 436,
b.tastarch, 408.408" 436,
nomlal ...rum albumin. Se~ Norm.!
... rull1albulI1in
pla,ma protein fraction. 403,408"
436.436,
ANTAGONISTS
,lib.",,,,,,,,
M,
,arnitine for hnrt faUur~, n51
ca~nn~ for nlUKular tension, 2731
d o"", tor dental pain, 242,
cotnzyme QIO for hrart di .. a .., 2901
cranbtrrylor urinary ,)"t.m btalth, 42St
868
Index
(cont.)
~chinaua for
immun ~ syst~m
4 53t
~""ning p.imrost oil for pain, 234,
flsh oils for inflammation, 470,
garlic for aordionscular h.,.]th, jl!,
ging~. for gastroint~Slinal disord~.s, 616,
ginkso fordem~nlia, 258,
ginseng for m)'X'lrdial ischemia, .l49,
gluwsamin~ and chondroitin for
osteoarthritis, 743,
gokl~n",al, antibacterial p.oprnies, 501 ,
gra~ ",I ""tracl fo r hyp<rtension, 303,
hor~hound for respiratory disorders, 584,
hor",ch~stnut for ""nollS inrufflciency,
413,
for insomnia, 153t
kava for anxiety and insomnia, 153t
ulogtnic diet fo r .. uur.., 169,
melatonin for insomnia, 153,
milk thistle for alcohol liver damage, lOSt
saw palmetto, 726,
"'" ""g~lables, 643,
selenium for cancer prevention, 549,
S!' )ohn"'M)rt ford~p ..ssion, 188t
val.rian for anxiety and insomnia, 153,
compl.m~ntary and alternative therapies:
attitudes toward, 96,
cultural and ethnic influences, 79
deflnition, 4
h~.bal, Su H~.bal th ..rapks
types, 961
com pia partial.,im.e, 168t
compliance:
d~flnilion,19
pathophysiology, 621
pha.macoth<rapy, Sec I.AVJ'lVl'.I
cont ... t dermalitis, 760
CONTIt.\.CEPTIVI.S:
ikpo-P""",ra, 697
Sa Emerg.ncy contracoption
emerg~ncy,
LibraryPirate
implants
desogesml.698
[mplanon, 697
)adell~, 698
lemnorgemd, 698
Norplant, 697--98
NUYalting,6'iH
oraL Se. ORAL CONTlACEl"lWES
Ortho-Evra,698
contractiUty.325
Controll~d Drug and Substances "cI
(Canada), 15
controUed .ub,tanc.., 14
Controlled SubstancesAct of 1970, 14
convulsion., 166, Seea/", Scizu ....
Copaxone, See Glatiramer acetate
capo, Set Chronic obnructive pulntOllary
di",a ..
copolym..- L Stx Glalirame. acetate
cop~r, 649<
Cordarone, Sa Amiodarone
Co.<'8, SeeCa ....edilol
Co.gard, Sa Nadolol
coronaryanerie... 339
coronaryarterybypa>s graft (CABG)
surgery, .l4O
coronary anerydi .... '" (CAD), 339, 341,
corpora """'mosa, 719
corpus lutrum, 695
corpus Mriatum, 257, 259f
Corrrciol. See Bisacodyl:
Phenolphthalein
Co.tef, Sn Hydrocortisone
corticosteroids, Sa GlUCOCORTIOOIDS
corlil:otropin,66O,
corti""ne, 470" 671t
Cortisporin, Se~ Polymyxin B, neom),dn,
and hydrocortisone
Cortrosyn, Sre Cosyntropin
Co ...... t, SN Ibutilide
Corzide, 302~ 422,
cosyntropin,660,.670
Colazym, Stx Pancrdip""e
Coumadin, Se~ Warf. rin
count..irritants, 741
CoY..a- HS, Stx V..apami[
COx. SaCyc100xygena",
COX- 2 inhibitors. Stx Cydooxygenase-2
(COX-2) inhibitors
Cozaa., SeE Losartan
crab lou"" 753
cranberry, 96~ 428,
""",tine kina .. (CK). >49t
Crestor, Sa Rosun,tatin
Crinone, SN Progesterone
CrWYan, Su Indin ... i.
Crohn', di"", .., 625
"romolyn.580,59fu
c."'s-toleranee, 106
crotamilon.753
Cruox. Ste Mkonarol.
cryptO<OC<XHis, 507t
Ctyp,ococevs n""form~n.s, 507t
Cfypt"'poridio,l., 521,
'IT"
5%dextrost in 0,2% saline, 433,
5%dextrose in lactated Ringer's, 433,
5%dextro", in normal saline, 433t
5%dextro", in Pla,malyte 56,433,
5%dextro", in water (D5W).
408t, 433t
hypertonic saline, 408., 433.
hypotonic 5i!lin~, 433,
laclatl Ring..... 40&. 433,
normal salin., 408" 433t
Plasmalyte,408,
Plasmalyte 56, 433,
Plasmalyte 148.433t
CSP., See CoWNY-STIMUIMING IlICfOiS
crz (chemo""ceptor trigg.. zone), 628
OIbkin, See Daptomydn
cullural competence, 78
cnlm ... , 78, Stx ~lso Ethnic/racial
consid<ratiom
culm ... and ... nsitivily (C&S) t.,ting, 482
Cuprimine, Se~ Prnil:illamine
Cushina', syndrome :
glucocorticoid therapy and, 471
pathophy,ioiosy, 672, 676
pharmacotherapy, 66Ot, 676
symptoms, 676
cutilneouo anthrax, 119,
Cutar, See Coal tar
Cyanapin, SN Vitamin B"
cyanocobalamin, Sre Vita min B"
cyanogen chloride, III t
CYCUC U!'J'OP[!'I1Dl'.I, 494
daptom)'dn, 495" 499
cydiLine, 630t
cydo bcnZilprine, 272.
aclionsand u ..., 272,
adrniniMration alerts. 272,
ad"" ... effects, 272,
int.ractions, 272 ,
OY..dose treatment, 272.
pharmacokinetics, 272,
Cyclofiex, SN CydobcnZilprin e
Cyclogyl, Sa Cyclopentolate
cydooxygena.. (COX):
forms, 228-29,467--68, 469,
functions, 228-29, 229/
in inflammation, 468
inhibition of, 468/
cydooxygena.. -2 (COX. 2) inhibitors:
action. and U"'", 228-29,467- 70
ad""r.. effects, 228,
celecoxib, 22&, 467t
route and adult do"" 228,
cydopentol.te, 143t, 774t
IndH
<y<lopho.phamide, 5561
action, and uses, 55&
administration al~rt" 5561
adverst dJect., 5551, 5>6,
interaction',556,
m~chani.m,ofaction,
550f
phamIaWkin~tk., 5561
rout~ and adult do .. , 5551
for :;pifi, ronditiom
canca, 5551, 556,
immunosupp",ssion, 458,
aUOPLfG1C5:
a tropin~, Sre Atropi""
charact.ristiC&, 774
cyd~ntolate, 774,
homatropinr, 774,
=polamine, 7741
tropkamide, 774,
CJ'doserin~, SOOI
Cyclooti, Se Bromocriptin~
cy<:losporinc, 4591
action. and u"'s, 457.459,
admini,tration al~rt" 459,
.dver", ~ffect" 4591
inU1'3ctiom, 201, 1001,4591
phaml"",kin~tic" 4591
for spifk rondition.
immunosupp",ssion, 459,
pooriasi" 762" 763
Cycrin, Su Mcdroxrprogcstero "e
>cetate
Cyklokapron, See Trane:camic acid
eylert, Set' P<moli".
Cpnbalta, Se DulORtine
cyproheptadine, 575,
cytarabin~, 550{. 554, 555,
CytoGam, Se Cytomrgaloviru, immune
globulin
cytokines, 451
cytomegaloviru, immune globulin, 450,
Cytomd, See liothyronin.
Cytosar, Se Cytarabin~
Cyto,ine arabino,id~, See Cytarabin~
Cytot= Se Mioopro,lol
cytotoxic T cdl', 4 50
Cyto'..,n~, Sa Gancidovir
Cytoxan, Se Cyclopho.phamide
D
D- and L-amphdamine rac~mk mixtu"',
198~ 200
D4T, See Slavudine
D5W, Su 5% dextro", in wat~r
dacarbazine, 555,
dadizumab, 457, 45&
dactinomycin,557,
Dalgan, Se Dewcine
Dalman", Se Flurazepam
dahoparin,374,
danazol, 7]2" 713, 7]7,
Danocrin., Sn Danazol
Damrium, Se.e Danl rolene ",dinm
dantrole nesodium, 2751
LibraryPirate
ddavird,ne, 530,
Drlestrogrn, Se Estradiol ,,.].rat~
delirium tremens (DT), ]08
Drlsym, Sn Dcxtromethorphan
dclta.9-t.trahydrocannabinol (THe) , 109
Drlta- D, Se.e Otol.cakif.rol
Drltasone, Se~ Predni "" n ~
deltoid 'ite, 32
dclushns, 204
Demad= Sn Tor"'mid~
d<meclocyctine, 4891
dementi. , 258" 263, Se.e a/so Alzhrirner',
uiotaK
DemeroL See Mcperidin~
[)mavir, Sn Pmcidovir
669
Drndrid, Sa Idoxuridine
d.ngu~ f~'..,r, 116,
Drpaken~, Sn Valproicacid
Drpakote, Se.e Valprokadd
Drpakole ER, Sec Va! proi< acid
Drprn, Sa PC1licillamine
d~prndonce, Sn also Substanu abu ..
d~finition, ]4
opioid, 1061, 227
Drp-MedroL Se.e M.th)'lprednisolon~
Drpo-Cyt, Sn Cytarabin~
d~polarization, 58
d.po]arizing blockers, l7S, Sn ,,/so
NIUROMUSCUIAR BWCKfltS
Drpo-M edroL See Methylprednisolone
Drpo-Provera,697, See ,,1<0
MMtoxyprosesterone acetale
Drpote't, See Te;tosteron~ Crriona!.
Drpo-Te.>tosterone, 718" See ,,1.0
T~sto't~rone cypionate
d'p",ssion:
a ... ssm~nt, ]83
characteri,tiC&, ]82---113
d~finition,]82
and rationales,
191---93,
patient and family education,
191---93,
planning: patient goal. and expected
outcomes, 191,
r-:>t~ntial nursing diagno", .. ]9],
pharmacothCTdpy
atrrkal antid.pr.... nt .. Se ATIPtc.u
="~
monamine oxida ... inhibitors, Sn
MON(w'UNE (llIDASE lNHlBITOlS
",l~ctive ",rotonin
uptake inhibitors.
Seo SIll:CI1VE SIltOfONIN llUYrAXE
lNH!IlITOlS
d.rmatitis:
charact~ri.tic ..
759-61
pharmacotherapy
immunorupp",.sanu,760
pimecrolimm,760
tacrolimu .. 760
topical glncocorticoids, 760, 760,
dermatologk preparations, 24
d.rmatophytic infection., 508, Se olso
M),<o"",
d~rmis, 750
DES, See DiethyistUbrstrol
870
Index
LibraryPirate
diltiozem. :HilI
aaion.and u .... 348,
adntinistratiOll alerts, 348,
ad""r .. effects. 343,. 3481, 360.
interaction 348,
owmose treatmmt, 348,
pharmacokinetics. 348.
for specific condition,
angina and myocardial infarclion. 343,
dysrhythmias, 360., 365
hypertension. 3071
dimmhydrinat~, 575,. 629, 630.
Index
dimucaprol, ]23,
Dim~tapp. See Bromph . niramine
Dim~tapp a,Udrm's Cold andAJl~r8Y, 576t
DIN (Drug ldmtification Numbtr), 9
dinoprostone, 703" 704, 708,
Diown. See Valsartan
Diown HCf. 302,
Di~ntum.
s.x OI...Jazin~
diphrnhydnmin(,576f
action. and uses, 5761
administration alert 576,
adYer,", ~ffts, 575t. 576. 576,
interactions, 576,
ph.mlacokin.rk. 576t
for spifk condition.
aU~'Ek rhinitis. 575,
anaphylaxi~
413
s.x ~r.o
ANT!OOAGULl.lmi
drugs cl.ssifled as
argatroban. 374, 374,
bi-;alirudin, 374, 374t
desirudin, 374. 374,
lepirudin. 374, 374,
m~chanismsof action, 374
dirithromydn , 489t
Disaldd. s.x Sal...Jat~
D1'EA.'iE- MODlFYlNG ANTIIHnJMATIC DRUGS
(DMARDs),742
adver .. ~ffts, 742t
drugs classified as
abat=pt.742,
adalimumab,742,
anakinra. 4Sg" 742,
azathioprin~, 74 2t
certolizumab pogol, 742,
rtan~rcept, 742t
golirnumab.742,
hydroxychloroquin . See
Hydroxych lo""l uine
infliximab, 7421
l.flunomid~ . 742,
m~thotruat. s.x Methotrn.l te
ritw:imab, 742,
rulfasalazine. See Sul fa",Ja zi ne
phamtaeotbtrapy with. 742-43
rout~ and adult do,"" 742t
LibraryPirate
871
aripipril7.ok.194~
215
2]3" 216
dopamin~
OOPAMINERGIa.:
872
Index
dmorubkin,553t
actions and uses. 558t
administration a1~rts, 558,
ad"""", dfects, 558t
interactions, 558,
"""rdo.. tn:atm~nt. 55&
pharmacokinetic.. 558,
route and adult d.,... 558t
doxorubicin liposomal. 557,
doxyo:ydine:
for acne. 756
ad"""", df""" 488--89.489,
mechani,m. of action. 48S--89
route and adult do .., 489t
doxylamin~, 161,577
DPaT. See Diphth~ria, tetanu . and ""nm.i.
vacdne
DPI (dry powder inhalrr). 591. 591/
Dramamine. &. Dim.nhydrinat~
Driodol. See Ergocalciferol
Drimral. See [kxbromph~niramin~;
P..,udoepbedrine
dronabinol, 629, 630t
dron~darone. J60" 364
drop at\llcu. See Atonk 5I"iml'l'
dro""ridol, 248, 252t. 629
drospin:non~. 698,
dru8(S):
administration. &. Drug administration
administration ~rron. &e M..dication
errorhl
Canadian approval P='s, 9, 9,
ronsumer spending on,S
cost, for old.. adults, 8,
ddinition.4
d~dopment cost., 8
FD" approval pro<e..
nurses' panidpation in, 9
n:cent changes, 8--9
'\lIg~s, >-8, 7/
time l~ngth, 8t
timetin 7/
inl<'raction.
with grapefruit juice. 20t
"""r-tbe-counter. 4
pa ... ~ through pla.ma membran ...
37- 3S. See also Pharmacokin~tics
pn:scriplion,4
reaction . See Drug reaction.
"'iulation, and standards, 4- 5. Sf
drug administration. Sualso
Pharmacotherapy
abbn:viation.,20,
compliance and. 19--20
.m~ral
LibraryPirate
guidelines
Ii>.., rights, 19
overview. 22
thn:cchecks, 19
inhal..d. 591
lifespan consideration.
childn:n. See Childr~n
infants, &e Infants
during lactation. &e B",ast-fn:ding
older adults, Su Old~r adults
in pr~gnancy. See Pn:gnancy
l"ung and middle-aged adult .. 72
nur .. '.responsibilities,18
nursing p=ss in
asse>sment pha .., 55--57, 56t
.... luation pha .., 59--60
implemenl3lion phase. 58- 5':1, 60.
nuningdiagno .... 57, 53t
planning pha .., 57- 58
ordm;, 20-21
pan:nt~ral
guiddin~s,
30-31,
2S. 29/
intramuscular, 29, 31 - 32, 32f
intrnvenous, 32, 33/
subcutaneou 28-29. 31f
pediatric. See Childr~n; Inflint.
religious fasting and compliance
wilh.24'
time schedules, 20-21
topical
guideline .. 26-27,
nasal, 25, 2S/
ophthalmic. 25, 27/
olic. 25. 27/
rectal. 28
for systemic .... Iocal df~ct .. 24-25
transd~rmal, 25. 25/
'YI~s, 24
vaginal. 27, 28f
transdermal, 25, 25/
Drug Enforcement "dmini"ration (DEAl.
14-15
Drug Jd~nlifk"tion Number (DIN). 9
drug im~raclions:
absorption and. 38
with grapefruil juice, 20t
with hcrb.tltherapies, 100.
drug--protcin compl=s, 39, 391
dru~ ",aclions:
anaphylaxis. See IuIaphylaxi.
Ste""ns-johnson .yndrom~, 18t
toxic q>idermal necrolysis, IS,
dry powder inhaler (DPI), 591, 591f
DTIC- Dome. &~ Dacarhaz.ine
Dukolax. S.. Bi .. codyl
duloxetin~, 186 188
duod~na1 ular, 609
duodenum, 620, 620f
Durag.n- l0. See Estradiol val~rate
Duragesk. Six Fentanyl citral.
Duralith. See lithium
Duramorph. S Morphine . ulfate
intrad~rmal.
E
car:
anatomy. 775. 775/
disord .... 775- 76
pharmacotherapy. See Otic
prrparation,
eadoop, 776
Eber's PdPyrUS, 3
ECG (cl.ctJo<ardiogram) , 356, 357/
cchinacea:
drug interaction., lOOt
amiodarono,365,
cyclophosphamide. 556,
nalomne hydro<hloride, 226,
sumatriptan.234,
testost.rone, 719,
for immune system enhancemenl. 453,
.tandardization.97t
u .... 96t
Echin"..,./Ipurpurro. Six &hinacea
fCIlINOCANDIN!:
anidulafungin.5O&,512
ca'pofungin. >0&, 512
echothiophate iodid 770,
. damp,ia,167
econazole, 513.
Ecsta.y, 110
ECf (ckctroconvul,ive (herapy). 183
. ctopk fod/pacemaurs, 356
eczema, 759. See also Dermatiti.
ED .. (median .ffective dose). 46, 46f
..drophonium. 140,
EEG. See Electroencephalogram
Index
efovi",n., 5321
action, and uscs, 532,
administration al~rts, 532,
adversc dJect., 530t. 532,. 533
interaction,. 100,. 532,
pharmacokin.lics.532t
rout. and adult do ... 530t
Effexor. Su V~nlafaxin~
elJka,y. 48{, 49
Effi~nt. Su Prasusrel
Efudex. Su Fluorouracil
Elavil. Su Amitriptylin.
Eldepryl. Su .sc1"8ilin~ hydrochlorid~
dderlydient'. Su Oldu adulUl
d~ctrocardiogram (ECG). 356. 357/
el~ctroconvulsive therapy (ECT). IS3
tltClroeno:tphal08ram (EEG):
in diagno'i' of sleep and .. izure
disord~rs, 153.166/
normal V5. abnormal. 166/
d~ctrolyt :
dermition.436
diuretic .ff~ct, on. 304
function .. 436
imbalancts, 436, 437 t. S& also spedf/{
e1ec,,,,ly,,,.
important in hu man physiology. 436t
renal rrgulation. 437. 438/
Elestat. Su Epinastine
detriptan. 233,
Eleunu""ocl'lt.'Jst'n,k-Ojus. Su Ginst'ng
Elidel. S<-e Pimecrolimus
Eligard. Su leuprolide
limite. Su Perm et hrin
El"""tin. Su Oxaliplatin
Elspar. See A>paragina..
dtrombopag. 391 '. 397
.mbolus.372
embryonic period. 65
Emcyt. Se. Esiramustine
Emend. See Aprepitant
.merg.ncy oontraception:
.thinyl ~stradiol and l~""nor~strd.
703.703,
levonor8~strd. 700. 703. 703.
.merg.ncyprepandness. nur ...' role.
117- 18
emesis, 625. See ~'''' Nauoea aoJ
""mitinll
emetic.629
emetk (rnletogen ic ) pot~ntial. 552. 628
emphY""ma. 601
Empirin with Codeine No.2. 223
emtridtabine. 530,. 538
Emtriva. Su Emtricitabine
EmulsoU. Se~ Castor oU
E-Mydn. Su Erythromycin
~nalapril. 319
enaldpril .312t
actiOll' and usc .. 312,
admini'tration alert'. 312,
adver .. dJect,. 31lt. 3]2,. 328,
interactio",. 312,
LibraryPirate
Sua""
int~ractions,414,
873
pharmarokinetic .. 414,
for .pecilk condition,
anaphylaxis. 413- ] 4
heart faUure. 335
'hoek.409,
epinephryl borau. 770,. 771
EpiP~n . 41 7 t. See also Epin~ phrin ~
epirubidn. 557t
Epival. See Valproi~~cid
Epi"i . See lamivudine
epl.rmon~. 303~ 311. 32S,. 423. 424,
epooetin alb. 3921
actions and uses. In,
administration alen .. 392,
adv~"", df~ct .. 39],. 392.
intera.ction .. 392t
Li~span Consideration,. 391.
Nursing Process Foeu .. 392--94,
o~..,rdose treatm~nt. 392,
pharmacokinetics, 392,
route and adult do ... 391,
EpDgfn. Su Epo"'in alf~
eprosartan.311,
EPS. See Extrapyramidal side effects
Epsom salts. See Ma8llesium sulfute
Epstein- Barr "iru,. 539
eptifibatide.379,
Equal""tin. SeeCakium polycarbophU
Erbitux. See Cellu:imab
Ereaf. Sn Ergotamin~ with caff~ine
=elile dysfunction :
cau .... 716t, 719
ddlniti<Jn,719
indd~nce. 7]6,
Nursin g Proces, Focus
a, ..ssment. 723,
....aluation of outcome criteria.
723--24,
implem~ntation
874
tndex
ANI'SfHFI1Q;
sO', F"'TA~;,,1
estradiol, 7071
estradiol cypionate, 707,
estradiol val.rat., 707,
estradiol/drospi.. non., 707,
estradiol/norgestimate, 707,
estramustin~, 555,
E5T1OGENS:
LibraryPirate
ethinyl.stradiol/no.. thindron.
acetat., 707,
conjugated estrogens. Se. Conjugated
.. trtlllen
estradiol, 7071
estradiol cypionate, 707,
estradiol yal.rate, 707,
estropipate.7071
ethinylestradiol. Sa Ethinyl ..tradiol
functions, 695
Nursin8 Process Focu.
as ..ssment. 7011
implemmtation
evaluation of outoom. crit.ria, 703,
inte"",ntions and rationalt., 70 1- 31
pati.nt and famUyeducation. 701 - 31
planning: pati.nt goals and l'l(I(Ctl
outcomes,701t
potential nursing diagno .... 701,
for >pe<:ifI, oonditions
dysfunctional uterine bleeding, 707
hormone .. placement thrrapy. Sn
HORMON. ilJ'L.'JJ.MENT THElAP'(
mnvifW. 704
estropipate.7071
esropidone. 160" 161
etanen:<'Pt.458" 742" 7621, 763
ethacrynic add.422'
ethambutol,5h
ethchlorvynol. 1601
ethin)-i estradiol:
for acne. 7561
adyer.. eff~d .. 7fYlI
for can",r chemotherapy. 560, 5611
in oral oontracepti"" .. 695. 6981, 707,
in tran<d.rmal patm, 698
ethinylestradiol with lemnorgestrd, 70},
ethinyl estradiol with no,..,thindron~, 700,
actions and list" 700,
administration alert .. 700,
ady.....ff! .. 700.
interaction,. 7001
pharmacokinetics.7001
ethin)-i estradioVnorethindrone aC<tat.
707,
ethionamide, >DOl
ethnicity. 79
<!hnic/racial OOIIsid.rations:
ACE inhibitor action. 3111
angina, 341 ,
communication technique .. 591
depr..sion treatment, 1821
dietary habits. 2861
enzyme ddkiend .., 50,
healthcar~ . cc .... 791
in immunization. 451,
mental illn .... 2OS1
osteoporosi., 7401
pain expr~ssion and Jl<""ption. 220,
pharmacotherapy, 78---79
tobacoo U". 1121
etho.uximid~,
1761
actions and u..,.. 1691, 176,
administration alert .. 176t
ad,..,r .. df""t 174" 176,
interaction., 1761
oyrrdo .. treatment. 1761
pharmacokinetics,176,
route and adult do ... 174,
Ethrane, Sre EntIurane
ethyl aloohol. Se~ Alcohol
etidronat. disodium, 7361
etodolac, 228,. 4671
etomidate,2511
etoposid 550 559. 559,
.traYirine, 530,
Eulexin. Se. Flutamide
EurJL Sre Crolamiton
",,"l.... tion pha ..:
definition, 59
in drug administration, 59----60
. "ming primrose. 961, 187~ 234,
Evista. Sa Ralm:ifel1e
awriation, 759
cxuetion. drug:
definition, 40
facto .. affecting, 4 1
m""hanism .. 38 40-41
in older.dult., 74
in pregnancy. 65
Exdderm. Sn Sukonazole
E:x.lon. Six Ri';.stigmine
nemestane. 561. 561,
nenatide. 6871, 688-89
nen:i ..-induced asthma. 592
exfoliati...., dermatiti .. 7611
E.dorge, 3021
Ex- Lax. Sn Phtnolphthalein
EXPCfOiANTI. 584
guairen..in. 5831, 584--115
extended-s~ctrum p<'nicmins, 4841, 485.
Sn ~Isu PENlOIJ.!NS
external otitis. 775
extracellular Uuid (ECF) oompanment. 431,
431/
enract.98,
extrapyramidal side effect, (EPS):
with antipsydtotic drugs. 206, 2071
definition, 206
in I';"kin<e"'.'
~i""" ... ,
2S7
ey~:
F
5- FU. Sn FluorouracU
Factiv~. Sa GerniU"""dn
falls:
benzodiazepines and. in old.. adults,
1581
Index
famddovir, 538,
family t~aching. See P~ti.nt and family
..ducation
famotidin~,612'
LibraryPirate
P""""
f~""rf~
drug interactions
aspirin,230t
"'"p ....fe.n.4I;9,
oyervi~w, 100.
warfarin, 376.
fexofonadi n~. 575,
Fi~rCon. See Caldum polycarbophil
HBilC ACID AGENn:
3d,'!'r5l' effens, 2871
drugs d""ifi..d as
dofibrate, 287t
knofLbrate, 287.
knofLbrk add, 287.
~mfibroLU. See G.mfibroril
Nursing Process Focus. 292- 94.
pharmacotherapy with, 291
route and adult dOS<"., 2a7 t
fLbriUation, 355
fLbrin,370
fLbrinogrn, 370
fibrinolysis, 371, 371/
fight-or- flightrespon .., 128, 128/
filara,tim , 395t
actions and u .... 394. 395t
administration a1crts, 395,
ad"" ... offts, 3911, 395t
int.radion .. 395.
n" .. ins p=" roc"., J96.
pharmacokinetic.. 395.
route and adult do ... 391.
fLltrate, 418
FinacN. Set. Aulak acid
fin a,terid e, 7271
actions and u .... 727t
admini'tration alerts, 727.
ad""".. .. ff!S, 7251, 727t
interaction .. 727.
pharmacokinetics, 727.
route and adult do .. , 725.
fi,..t-pa .. ~ff""t, 40, 40/
fLshoils:
for inllammation, 470,
uses, lOOt
fLve rights of drug administration, 19
Flagyl. Su Metronidal.Ol~
flaXSetd oil, lOOt
lIainid<, 3591, 360,
875
lIudarabin~,
555t
lIudrocortison., 671
FWID AND !'LOCIWUTE IEPVEMENT AGHns:
s.:llnflu~nza, ",,"ine
876
Index
fWOIlOQl!II'IOt.OtIES,
(CO" . )
.hird,eneration
aaIiAoxadn,492,492.
IoMlfloucln,492.
m .... nISITII of lKtion, 491
p!l&nmlocolhn'apr with, 491-92
roule and odult do$ts,492.
fluollllJ.-.ctI,5~f. 551 554,555., 556{
flIWtmnf. S U.lothauf
fluOMline. ISS" 1861,266
lIuoxyme5leron(, 560, 561" 717.
lIuphenazine, 206.
lIunndrenoUde, 760.
lIunupam, 157,
lIurbiprofom, 228" 467.
lIutomide, S61,S6lt
lIulil<lwlJe,Snl
lKtionsand UK!, 577.
administntion alert!, 577.
odvnw effl!' 577., 580., S96,
interaction!, 577.
pnarmacokinella, 577,
for ipiS, conditio."
a1le'llic rhini([" 580.
asthma, 596.
dermatitis, 760.
lIu"".tolin,287,
Fluvirin. Set lnAuen;r.a, vO(Cine
lIumumine, 155" 186.
Fluzonc. Set Influenu, vaccine
Fobrin.
Folic Kldlk>bu
I'OIJC foCID AtlTACONIST$. Sa abo
s..:
""""'~
melhottUot( . Sa Mcthotraote
pemtlr~, 555.
folk odd inhibitors. Set SIJ\.J'.otW,IIDES
folicadd/fohle, 399, 61
ad>Tr5e effccts. 39&
for anemia, 398-99, 398,
ddlciency, 399, 399',640.
functions. 492. 640.
p .... rm..:othenpywith.399
..:lIonl and uses, 644,
odministratlon akns,644,
odvns-e effu.. 644.
iDltHCIions, W.
p .... rmxokinctlcs, 644.
roule and adult dose. 398., 644.
in I'n-enanry, W'I,. ~19t, """,
recommended dlctar, allowance, 6Wt
5OutCeJ,644
structure,5S6/
foUideslimulatlng hormone (FSH ):
for f.male Infertility. 7[2.
in female reprodU<:ll~ function, 695.
697/
in male reproductl~ function. 7[6
sccretion,658/
foIliwLlr ctIIs, 662
FoIloom.Sa FoUltropin beta
roIlilropin a1fa, 11:!l
foUitropin bda, 712.
Foivile. Set folic add/folate
LibraryPirate
forn.pIz.lle, 1231
fooo.parinux, 374,
Food an~ DlU,Adminmratlon ( FDA):
medlcotion ([!'Of rrponing, 87
Med~';tICh,87,91
-",
Fta8JI1ilL Sa DaI'cparin
Frank-Surlin, law, 325
frequency distribution curve, 46, (6/
huh froun pluma, >lOs.
Frov... S I'rov;Itrlptan
fl'01lllnpian. B3.
FSH. Stt Foillclestimulating hormont
FUDIl S. Floxuridinc
fulve5Innl.S61'
Ful.lein. Set Grlsrofulvln
fungall~ftion5.
Su Myrooc"
G
G6PD (g1ucott-6.pOOsp .... te
dehydrOi'"na ... ) ddkiency, SOt.
47)',517.
g;aboptntln:
adv~neeffu.. 171t
"""""
ganddovir,S)8,
ganglionkblod,en, Ill, 278
ganglionic $filiP"', 129
ganlrellx ~.te, 7 12.
Glnlnsln. Su SulfillOUZOlc
Garamycin. SetGtnll.mkin
Gard:alll. Su Htunan papillomavirm ...."Ine
Sorlk'
forcardiov.scularhcahh,3721
dlUg intenClions
IIp ....glucosidase inhibitors, 688
uplrln,23ll.
Ibuprolr:n, 469,
Insulin,683.
oycrvicw, 100.
~rfarin., 3761-
-'"
5lO.
adjunctl
borbituratn
amobarbital Su Amobarbital
Index
".
LibraryPirate
gmeric name, 13
genetic poLymorphisms. SO. 81.
gmetics:
influmces on pharmacotherapy. SO. 8] I
.. izu", etioLogi.. and. 167.
~notropin. See Somatotropin
~ nl amkin , 491.
actions and u .... 4911
admini,tration al.m. 491r
ad", ... effects.49lt
cream and ointment. 752
interaction .. 491.
pharmarokinetk.. 491.
rout. and adult do .... 491t
~mran 40. Su IHxi.dn 40
~ntran 75. See Oatran 75
~ociUin. Su Carbenicillin
~odon. Sa Ziprasidon.
GERD (lla5l:"",sopha~1 ",flux di .... ..,J. 609
gestationalag drug therapyand.65
lIestational diabet~, mellitu .. 680.
GFR (glomerular mtration rate). 419
GH (growth hormones). 659-00
Gi~rdw "'",h/i<l, 521t. 5D.
gianlia~i~. 5 21~ 5231
ginger:
drug interaction.
aspirin. BOI
ibuprokn.4691
oye .... i.w. lOOt
warfarin. 3761
for ga.trointestinal disord.rs. 6161
standardization,97.
u..... 96.
ginkjlO:
for d.mentia. 258t
drug interdctions
altepla .... 383,
aspirin. BOI
htparin.3751
ibuprokn.469.
imipramin IMI
oy..... i.w. lOOt
n:t.pLa .... 35It
.uma l riptan.234,
formulations. 97/. 98.
labeling, 97f
standardization.97,
""".96.
877
878
Index
GWCOCOJtTJCOIDS, (ront.)
for .~cific condition.
adrenocortical insufficiency. 671. 671,
a11.rgk rhiniti . Su lNTlANAMI.
GWcocomCOIDS
ANTAGONISTS:
ad ......... dfcct., 3791
drugs dassifitd as
abdxim.b, 349. 379,
.ptiftbatid 379t
tirofiban.379,
mechani,m, of action. 380
route and adult do .... 379,
glycopyrrolate.143,
Glyna .... Su Glyburid.
Glyset. Su Miglitol
...
'
d.flnition.57
in drugadministr.tion. 57- 58
OOLD SAII"S, 743
8OId.n",a1. lOO~ SOl,
I/Onadocorticoids. 667
8Onadordin. 712. 712,
gonadotropin -n:l .. ,ing hormone (GnRH).
695.712. Sffalso Chorionk
gonadotropin- HCG
Gonal- F. Set Follitropin alfa
JIO'Iorrhra.480t
Gordochom. St"<" Und.cyl.nk add
8O ... rrlin. 56lt. 712,
80m-kola. 158,
I\0Il1 :
eharactrri,li"".743
elas.ifkation.743
pathophysioIOflY.743
LibraryPirate
granulocyt./maerophas. colony_
stimulating faclor (GM -CSFJ. 394.
Sff also CoWNy- mMUlATING
~"
H
H .. K-IUP.... , 6IJ
H,_n:crptor.575
H, -REUPTOi ANTAGONISTS:
adya .... fJeet., 575,
combination. wilh dcconge.>tants, 576,
drugs d."ifled as
flrst _grnrration
aulastin 57S,
brompheniramin 575t
chlorph.niramin 575t. 576
cl.maotin 575,
cyproh.ptadin 575,
d.xbrompheniramin 575,
dexffiJorphrniramine.575 ,
dimrnhydrinatr.57S,
diphenhydramin . Ste.
Diph.nhydrnmin.
prom.thazin . S<Y Promrthazin.
triprolidin . 57S,
orcond-gen.ration
crtirizin~. Ste. Crlirizin.
drsloratadin 575,
fexof.nadin 575.
1'''''''''irizin 575t
loratadin 575,
olopatadin 575,
Nursing Pr""ss Pocus
a' ..... ment.57S'
Index
sympt"m .. 326
H~ctoroJ. Sa DoRrcakifcrol
Hdicobucterpylod. 609. 61Of. 615--16
hrlminth .. 507,. 517. Sauoo
ANI1HEIMn;rn[CS
LibraryPirate
od d
apro!inin.386t
tranexami< add. 386,
IIlhanism. of action . 373. 373,
route and adult do..., 3,0,6,
hepa rin, 375 t
actions and u .... 375,
administration alerts. 375,
ad"" ... dfc<ts, 374,. )75,
interaction .. lOOt. 375,
overdose t",atment. 375t
pharmacokinetics, 375,
route and adult do ..., 374,
heparin anti-Xa. 372,
hepatic mkrosomalenzyme system.40
Hepatic -Aid II. 651
hrpatiti .. 540
hrpatiti' A, 540--41
hepatiti.A immunoglobulin (HAIg). 541
hepatiti." wccine. 452~ 541
hrpatiti. B. Il6t
charactrristks, 541
pharmacotherapy. 54l. 542,
hepatitis B immunoglobulin (HBlg).
450 ,.54 1
he patitis B vacci ne, 4531
actions and u .... 453t
admini.tration alerts. 453,
ad"" ... df""". 4531
interaction .. 453,
pharmacokinr1ics, 453,
5Chtdul~and
452,. 54 1
hrpatitisC :
characteristic.. 541 -4 2
pharmacotherapy.542t
.gr.
879
"I..,
therapies
b,,51- .. Jling. primary u .. s, 96,
d assification.538-39
e~ infrctions. 539
in cidtnct.5271
Nursing Proces, Focu.
as ...smrnt. 542,
n-aluation of out",mecriteria. 544,
implementation
interwntionsand rationaLe.. 54.3-44,
patirnt and family education. 543--44,
planning: patirnt goals and cxpc<trJ
outcomrs, 543,
potrntial nursing diagno ..... 542t
phamIawth.rapy. 539. &~,,'so
Am~
BBO
Index
implem~nt.tion
LibraryPirate
abc EsrIOGENS
ady...... ffocts, 7Il4- 5
benefits, 704
NUr>ing Proct" Focus, 701 - 3,
HOlMONES:
functions, 657
pharmacotherapy with, 659
produaion, 657. 658f
horny goat ......,d, 96t
horso chc:stnut. for ",,"ous inrufficirncy, 413,
host 1I0ra. 483
hou",hoJd system of mururemrnt, 21. 21,
HPFB (Hc:alth Products and Food
Bnnch).9
HRT. See Hormon. r."lacc:m~nt therapy
HTN. See Hypcrlrn,ion
huffing. 106,
Humalog. Seo Insulin lispro
human chorionk gonadotropin (HCG).
712, 712t. 718. 718,
human immllDOlkficic:ncyvirus (HN ). Seo
~Iw HlV-AlDS
posl."PO'ur. prophylaxi, foUowing
occupational rxPOSUK, 537- 38
pr ..... mion of perinatal tran5mi"ion, 537
rc:plication, 528. 528/
.tructu",. 527f
t .. ting for, influ~nct.on. 529,
transmission, 528
human in!t2ration pyramid cart mod.1.
77,77/
human papillomaYiru. Yacrin., 452t
hum an "'Sul ar in . ulin, 683t
aaions and uses, 683t
administration alerts, 683,
ad ... r.. dfects. 682" 683t
im. raction.,683,
o\"erdo5C tr~atmrnt. 6113t
pharmacokin<1ics.683,
rout. and adult dOS<". 682,
Humatin. See P.romomydn
Humatrope. Seo Somatotropin
Hum<gon. Ste M~notropin.
Humira. Seo Adalimumab
humoral immun. r.. pon ... 447, 448/
Humulin N. Seo [sophan. insulin
.uspension
Humulin R. Seo Human rc:gul ar in sulin
hungor,631
Hunling!on', chorea . 256,
Hyalgan. Seo Sodium hyaluronat.
Hyrodan.584,
Hywmin. Compound. 584,
Hywtus. Expectorant. 584,
JIYrnmoINS:
Index
interaction" 319,
o""rdos. tmU ntrnt, 319,
pharm"",kinr lk&, 3 ]9,
for spifk condition.
hean failuJ't , 328., 334
hy~rte",ion, 319t
Hydrwti.! """ad.",;., SeeGolden....1
Hydrea. Sec Hj<lroxyuJ'ta
h~hIo rothiitz.id ~, ,1041
"'''
inttTactiom, 3().t,
o""rdo.. trtatment, 304.
phamlacokinelks,3().j,
for spifk conditio",
hean failure , 328.
hy~nension, 303t
",nal failu ... , 422.
hydrocodonr:
adYersc Iffrcl . 222t, 583.
asamitur.siYe, 583, 583,
for pain manag~ment, 222<
routl and adult do ... 222t, 583.
hydroco rtisone, 673r
actio", and usc .. 673.
admini.tration alerts,673.
ady.... effrcl., 470t, 671 . 673t
inter-dctions,673,
pharrrtaCOkinrlics,673,
for spifk condition.
adl'tnocortical insuffidency, 671.
dermatitis,76Ot
"ar irrilation, 776t
inflammatory bowel di ....., 625
psoriasis,76t
inflammation, 470.
Hydrocorton . Sec Hydroco rtisone
H)droDlURIl. Sce H)'drochloro1hi azidc
hydrogtn cyanide. 121t
hydromorphone hydrochloridr, 222t
hj<lroxydl lo roq uine, 7Hr
action. and uses, 743.
administration alert., 74 3.
ady.... effl., 516t, 742., 743t
interaction., 743,
o,.."do .. trtatmrnt, 743.
phamIacokinetic. 743t
route and adult do", 516., 742.
for spific conditions
malaria. 516,
rheumatoid arthriti .. 7421
hydroxyul'ta, 563.
hydroxyzinr, 161, 630.
Hygroton. Sn Chlorthalidone
Hyoocine. See Scopolamin"
hyoscyaminr,625
H~rab. Set Rabies immunr globulin
hyprraldosteronism, 670
hypen;alcentia:
ddinition, 437.
"""I't
LibraryPirate
primary, 299
secondary. 299
hyprrl<1lsi,.., emergency, 319t
Hy~rTer. Se~ Tetanus immunr globulin
hyperthyroidi.m:
cau .... 662
inddrn"',662t
pharmacotherapy, 663-64. Sn ~Iso
hy~rkaJrmia:
h)'P"nonic solutions:
cltaractrri.tics, 431, 4 321
uystalloid, 433, 433 . Se~ "/.,,
causes, 438
d.finition, 437., 438
pharmacotherapy, 438
potassium.sparingdiul'ttic. and, 304
in I'tnal failure, 420.
rupport;ye treatment, 437,
hyptrlipidrmY.1SS. See also Lipid disordm
hy~rmagn~mi . 437t
hy~rnat"'mia:
in athlerl., 438.
cau .... 437
ddinition. 437,437.
pharmacothrrapy, 437, 437.
hy~rosmolar hyperglycemic statr
(HHS), 682
hy~ro'molar ",,"utotic coma
(HN KC) . 682
hy~rpho,phal<mia, 420 . 437.
hy~nr",ion (HTN) . Se~also Blood
p ........
""-"'"
INHlBITOIl>
adrenergic af,'Oni,u. S AlPHA_
ADRENERGIC IoGONI!IT'
88 1
hNTITHYlOID t.G!Nf~
CRYSTAllOIDS
salinr.408.
hypcrtrigl~ridrmia,
882
Index
carn, (amI.)
OClrtQIide, 6241, 660, 611
HYPOlHAv.MIC ...
~nl,6601.661
hypothalamus!
in anIitty, ISO. 151/
dioordM"S,6S9
borm<)R( production. 54&, 653/
in hunll..,.,631
hypo!hyroidlsm:
.miod.uone~nd, 663
inci<;lenct, 662,
pharm.cOl hCTapr, 663. Su "Iso THnOID
~~
ADHD,200
arulrlr symptoms, 1551
depKsslon, 186,
mi, .. ln., 2331
lmitra.Set Sltma tript~n
IMMUNE Gt.OlIUl.II<fo:
in >hili worUrs,6631
symptoms, 662-43
hypotonk ""'Ullons:
duracteristla, 43], 43l{. 436
ooIloid. SCOUOIDS
crystalloid. S 0:Ysv.u.0uJs
~ sbock, .o6, 4011
Hysmn. S Dutnm 40
Hytakrml. Set Dlh)UrOla<:hr>tcrol
Hytrin. snruosln
Hyzaar,302<
cyto{1l~loviNI
passi~,
11J] !ktRadIo~cti...,iodlne
ihandron.te, 7)6,
ibritumomab tlmetan, 5631
Ibul"""f... , 4691
lClions.nd I.IK"S. 468-69, 469t
adminlltralion alerls. 4691
lMMunOST1MUL\.~
lMMunOSUJlI'RDSANn
~dfms.12i11.~.~1
29f, XlI
idarubicin.5S7.,55S
idinpa1hic hypert ... sioo, m. S
"""'rn"'"
449, 451/
.wo
idiooyncl"llt ic mponSft. 50
idor.uridine. S33,. 539
IfeI. Set If05f.1mkk
ifosf.mide. SS5.
arum, 620, 620!
iUnoion!, 2()4
1M (inlramuKular) dru8 administl"llti<>n,
29,3(11,31-32. n!
imalinib mcsyl.\(, 56h 564
Imdur.s IJOfIO.bide mooonitl"llte
imipc ....... dlalt.tln. 4951. 499
illlip .... ,,;nt. 1871
lClionsand usn, 181,
adminlltnlion alerts. 1811
adwtv dftl:ts. 155,. 187~ 233,
LibraryPirate
(Ba.:;)
',"eelnc, 454,
inl,rftrom. S IN"ID.FERONS
!r:vlll1OO1 5fi31
Nurllns Procnl FoeUI
aUUSmtnl,455,
e""' ..... 11oo or oulOO...., aileria, 4561
Iml'k....,ntalion
Inte,....,nllons and rational ..,
4S5-5fi,
p.11;enland f.un~yeducation,
455-56,
pla.,nlng: palienl goals and expr<:lro
oltl,omes,",55,
pot.nllal nUriing diagnose!, 4551
pharmaoothcrapy with. 452- 53. 454,
rouleand adult doses, 454,
IMMUNo;UPPl~:
an~mtubolitft
...... "
s..
68-69,69/
InrilSUri S. Calfactanl
Inrtlousa",nts., 1111
lnkcr!ouJdista ..... 1]61
Infuatn. s Inlerfm>n a/fawn. ]
IndH
infertility, 712
fcmal~. Stx F""",1e infertility
m.al~, 718--19
infiltration an<"Sth.osia, NO/, 241,
inflammation:
dt~mical miiators, 4651
classification, 465
d~f,"ition, 465
fISh oils for, 470r
function, 465
phaml.ilcotb.rapy, 466
glucocorticoid . Me GlucocomooIDS
non.tuoidal ami-inflammatory
drugs. Stx NONSlUOI[O'..L
ANTI-INFlAMMATORY DRUGS
pro<e ., 465, 466f
inflammatory bo\\"~l di!ol'a~, 615
inflammatory disord .... , 465, 465,
infliximab:
adver ~ ~ffts, 45S,
as irnmunomppressant, 457, 4 58t
for inflammatory bowd di .. a ... 625
forp""ri i., 762" 763
for rheumatoid arthriti., 742,
influtrtza, 116t, 540
prophylaxis, 540
amantadin. , 257, 258" 540, 5401
rimantadin., 540, 540,
va"in~. 452" 540
tr.atment
osdtomivir. 540, 540,
zanamivir, 540, 540,
infusion, herbal, 98t
INH. Me honiazid
inhalation anthru, 119,
inhalation, for drug administration,
591,591f
inhalations, 24
lNHAllD GWCOCOmooIDS:
ad"er~ ~ffts,
5%t
for asthma. 595. 5%" 599
~lometha"'n . See B edo~tha.on e
bud"""nid~, 5%t
dde",nid. ,596t
fluni",lid~. 5%,
flutica"'n~. Set Flutkaso ne
monlda"'n ~, 5%t
triamrinolon~.
s.-. Triamdnolon~
Innohep. Me Tinzaparin
Innovar. Set l'entanyVdroperidol
Inowr. See Inamrinon~
lNO"mOPlC AGlNI"S:
drugs classified a.
digoxin.. Me Digoxi n
dobutomin~. Stx Dobutamine
do""mine. See Dorami""
m ~ chanism. of action, 4 12- 13
inotropic effect, 325
in ,omn;':
anxiety and, 152
d.fmition,152
indd~n"~, 153t
insulin ""i.ton"" and, I 53t
LibraryPirate
Iong-1et"m,152
natunl th.rapi~., 153,
pharmacotherapy
antihistamines, 577
antiseizur. drugs, 160. Set aoo
AN"I1SflZUlE DIUG.
harbiturates, 159,. Stx ah.,
iWtBmJII.l.ITS
b.u-adr~n~,%iI:
noab<nzodiazepin., nonbarbiturat~,
160,. Stx ,,00 NONBrnZODIAZEPlNI'.,
1I0NMRBITUlATE CNS DIl'ItF..>S.I.NI"S
r~boll1 d, 153
"'-'"
pati.nt and family iucation,
",-",
pla~nin8: pati~nt
preparations
human r<"8ular in.ulin. Sre Human
~~uJarin .u lin
1183
aJfa -2b
int. rf. ron alfacon, 542,
interftron alfacon- l, 454.
interftron alfa- n I, 542t
interftron alfa- n3, 454,
int. rf. ron beta- la, 454,
interftron beta- I b, 454,
peginmferon alfa-2a.454 542~ 562-fi3
r<%int~rkron alfa-2b, 454" 542t
mechanism. of action, 452
Nursing Process Focus
assossm. nt, 455t
n-aluation of outcomo criteria, 4561
implenl~ntation
int~rventions
and rationales,
455- 56,
pati<nt and family iucation,
455- 56 ,
plannins : patient goal. and exp:t~d
outcomo., 455,
pot. ntial nursing diagnose., 455t
pltarrnacotherapywith, 452- 53
for .peciflc conditions
cancer, 562-fi3, 563.
htpatitis, 541-42, 542,
lNTEl LEUllN. (ILs):
ald~sl~ukin , 454" 563
d~flnition,453
mechanism. of action,453
oprdvekin, 391" 397, 457
intermin~nt daudication . 379" 380
intermittent infu.ion, 32, 33f
Int. mational Union of Pur~ and Applii
Cb.mistry (iUPAC ). 12
interper",nal th~rapy, IS3
int~rstitial space . 431, 431f
int. rventions:
in miication administration, 60,
int ..""Uularfluid (ICF ) companm~nt,
431,43lf
intrac~Uular parasites, 527
884
Index
inlrad~rmal
LibraryPirate
"".-I
J
JadeU., 69S. Se~ alw Lemnorgest",l
Januvia. See Sitagliptin
jejunum,620,620f
jock ilm, 5071, 514
K
P. Se, Potassium
See Calcium glllconate
Kaldra. S<e Lopina.ir/ritonavir
kanamycin, 490t, SOOI
Kamra. See Kanamyl:in
kappa receptor .. 221, 2211, 221,
ka\.,.:
for anxiety and insomnia, 1531
drug interactions
,hlorpromazine,207t
dia,.,pam, 173,
haloperidol, 208,
lorazepam. 15&
ntorphine sulfate. 223t
phenobarbital,I72,
risperidon.,212.
thiopental, 251,
parkinsonism and. 260t
standardization,97t
KaycxaLlIe. See Polystyrene sulfa"
KCI. ~ Potassium chloride
K-Dur. See Pot a", ium c h!orid ~
Komadrin. See Procydidine
hydrochlorid.
Konacort. See Triamdnolon.
Konalog. Se~ Triamcinolone
Krppra. See levetiracetam
keratolytic, 756
Korlonc. See Iktaxolol
Kttalar. See Kotamin
ketamin~, llO.24S.251,
Kttek. SeeTelithroml"in
ketoacid .. 680
ketoronazole,513,
ad .... r.. effects. 5131
for Cushing'. syndro""" 676
int ~ ",cti"n<. 20',100.
route and adult do .. , 512. 513t
ketogenic diet, 169,
nTOllD!'.I, 499
tdithromydn, 495" 499
ketoprofen, 22SI, 4671
ketorol" trom~thamine, 228,
KI (pota .. ium iodide), 120-21,650, 667
kidneys:
disord~rs. See Renal failure
drugs toxic to, 419,
function .. 4 18, 4191, 438f
transplants. 4\8,
Kin~ret. See Anwnra
KlclJsiellll. 480,
Kalcinat~.
Index
Klonopin. SuClonaupam
Klor-Con. s.., Pot~ ... ium ch lorid~
Konsyl Fi~r. s.., Calcium polycarbophil
K-PhosMF. Su Monobasic pota"ium and
sodium pho,phat~.
K-Ph05 nfUtral. & . Monobasic pota"ium
and sodium phosphate.
K-Phos original. s.., Monobasic pot ~ .. ium
pbosphat~
L
la~talol.
315t
lact~ .. d~hydrogtnase,
349,
lactalro Ringer's, 408r
lactation. See Breast-f.eding
I ar:ttlbarU/u.'
"";Mpltilu.~
100
fin.
Lamiclal. &.Lamotrigin~
Lami.U. Sa T~rbinafin~
lamivudin~,530t. 538, 542,542t
lamotriginr:
~dvasedJI5, 173t, 194,
forbipolardisordtr, 193, 1941
for .. izures, 1691, 173.173,. 175
Lampit. See Nifurtimox
lanoUn alcohol, 7741
Lanoxicap .. Sa Digoxi n
Lanoxin. &~ Di goxin
lansoprazoJ., 6111
lanthanum calbonar., 4201
Lanlu .. &tlnsulin glargine
lapatinib, 5631
larg<"-volum~ infusion, 32, 33f
Lariam. &e Mdloquin~
Larodopa. See L",nd"""
Lasix. &e Furosemide
lalanoprosl, 771 t
action. and uses, 769, 771,
administration al~rts, 7711
adver .. dJu, 770t. 771,
intaactions,77I,
2&3
lenalidonide,564
lepirudin. 374, 374,
l<pro<y, ~80" 501
lescolSn FluYa'tatin
l"'rowl., 561, 561,
leucovorin. 123,
lcuk.",i. 549,
uuman. Sn ChJoramhu(U
leukine. Se< Sargramostim
leuropo:esi., 394
I.IUWfIIl:NE MODIFIERS:
I,uprolid ~ :
rout~
LibraryPirate
as5
implant., 697--98
in oral contrac"1'tiYes. 69g. 698,
u""ph~d. Su Nor"1'in"1'hri"e
lemrphanol tartrate, 2221
le..,throid. s.., levothyrminc
Itl'Othyro.rine. 664.
actions and use., 664,
.dministr-~tion al~n., 664,
~me ..... df~ct., 663" 664,
interaction., 664,
"""rdo.. treatm~nt, 664,
pharmacokinetics, 664,
route and adult do .., 6631
u-=yl. Set, kmthyrmi nc
lcwisit~ mixture, 121,
Laapro. See Esdt~lopram OXJ.lat~
Lai..... St.. Fosamprtnavir
uxxd,J02,
LH. s.. Lut~inizing hormon~
libido,717
Lihrium. Set: Ch!ordi=poxide
lice:
characteri'tics, 752- 53, 753f
pharmacotherapy. &" PEDICUl.lClDES
p<y<hooocial a nd community
impact, 755,
licorice, 423" 4711
lid",.i" e, 243.
actions and use., 243.
administration al~n., 243,
adve "",dr~ct .. 242t. 2431, 3601
ch~mical structur~, 243f
intaaction., 2431
"""rdo.. tre.tm~nt, 243,
pharmacokinetics, 243t
for .pedllc condition.
dysrhythmias, 359~ 360t
as local ane.th.rk, 2421
for sunburn, 763
Lifespan Considerations:
adve"" drug ~ff""ts in older adult .. 41 1
.g<"-rtlated issu ~, in drug administration,
."
.lcohol-rdated pancreatitis, 635,
886
Index
'"
~~Iin
7]8t
"",
LibraryPirate
~uation
329t
artiCiline, 242.
bupiwcain e, 242.
cb.mical .truCiUr<, 243f
dibucaint, 242,
lidocain~.
Su lldocai n~
242,
ropivacain~ . 242.
dydonine, 242.
prilocain~,
~st~ ..
243f
242.
procain~,
R>c".
implem~mation
555t
lon8't~rm
inOOJJUlia, 152
Loniten. Se~ Minoxidil
lOOP OIUlmc.l:
Index
anxi~tr, 157,
as intra.... nousane>the!ic, 251,
nausm and vomiting, 629,6JO,
..izurts. 169" l71,
asskddal mus<lt rolannt, 272,
losartan, 311,
Lott nsin. Sa Iknaupril
Lottn.in HCf, J02,
Loud, JOlf
Lotron= SaAlo.. tron
10'''OIatin, 20t, 2S7,
Lo .... no"" Sa Enox.oparin
low- d~n5itylipoprot~in (WL ):
dtaracttristiu. 2S3, 2S5/
laboratory yalu~s, 286t
ratio to HOt, 285
mbdasses, 2115
lowrr gastrointestinal tmet:
anatomy, 6()7f, 620/
di",rd~..
constipation, 621. Sa ~f", L\..UTlVH
diarrh~a, 622- 23. Sa~bo
ANI1DIMRHF..\.1S
incid~nc~,
621,
normal function, 620, 61fJi
low"" r~spiratorytmcl, 590, 590/
WW-MOIRuv.Jt-WEJGfIT HEPARIN,
(LMWHs):
adY~r .. dJu, 374,
dtar~ct~riotiu. 373- 74
drugsda"m.d as
dalttparin, 374,
.nox.oparin, 349, 374,
tinzaparin, 374,
m~chanismsof action, 373--74
rout~ and adult do .. , 374,
for spifk condition.
myocardial infarction, 349
throm~mbolic di .. a.., 373--74.
374,
lox.opine sucdnat~, 209,
Lro:itan . Sa Loxapin. sucdnat~
Lowl. Sa Indapamid.
Il'ROSTAGlANDlNl:
drugs da"m.d as
mi"",rostol,617
LSD, 109-10, 109/
L-tryptophan, 188,
lubipro'ton~, 622, 622,
WIIIICANT.>, OPHTHAlMIC:
lanolin alcohol, 774,
m~thykdlulo .. , 774,
polyvinyl akohol. 774,
Ludiomil. Sa Maprotiline
Lugol"s solution, 650,663~ 66-l
Lumigan. Sn Bimatoprost
Luminal. Sa Ph enobarbital
Lundk Su M~droxyprogestnnne ""<I. t~
Lun~.ta. &, Eszopidone
Lupron. Sa Leuprolid.
Lupron Depot. &, l.=prolid~
lutnnizing hormone (LH),658f, 695. 716
Lu",,""- Se. Flumxamin.
LibraryPirate
M
rna huang, drug int~ractions:
digoXn, 331,
loraz<:parn, 158,
pb.ndzin., 190,
Maalo,," Sa Magn.,ium hydroxide and
aluminum hj<lrru:id.
Maalox Plus. Sa Magn~sium hydroxide and
aluminum hj<lrru:id~ with
simtthicone
MIr.C (Mycohacteri~m ~vi~m complex),
,01
macrocytic antmia, 398, 398,
Manod.x. Sa IHxtmn 70
MAUOUDf.S:
ad ........ tr.cts,489, 489,
drugs cla!>Sifled as
azithromydn, 489, 489t, 50 I
daJithromyrin, 489" SOl , 616
dirithromydn, 489t
rrythromydn. Sa Eryth romycin
for H.pylori, 616- 17
pharmawth.mpy with, 489
routtand adult doses, 489,
MACiOMINEJ.AlS:
caki\Ull. Se, Cakium
charaoteriOlks, 648
<hlonk Sa Chloride
funotions,648,
magn"ium. See Magnesium
pharmacothtmPrwith, 647t, 648
pho'rhorus. Sa Phosphorus,lphosphat~
pota,,;um. Sr. Potassium
rODUI1~nded di~tary allowanas, 648,
sodiu:n. Sa Sodium
sulfur.648,
magaldm~ ,615,
magnesium:
functions, 648, 648,
imhalmas, 437<, 648. Sa "/,,,
Hl'P"rmagn.sernia;
Hypomagn~ ..mia
pharmawth~raPr with
ma~~'ium chlorid., 647,
m~n.sium hj<lrru:id . 615" 622t, 647t
ma~n~sium hj<lrru:ide and aluminum
hj<lroxid~ , 615,
ma~~'ium hj<lrru:ide and aluminum
hydroJ<id~ with sirn~thiron~. 615,
ma~nesium oxid~. 647,
ma~n~sium sulfat~. Sn Mlgnesium
.uJfate
rODUI1tnded di~!ary allowam,.. 648,
magnesium chl()J'id~, 647,
magnesium hydroxid., 615" 622" 647,
masn~sium
as7
hj<lroxid. a nd aluminum
hydrru:id ~, 615,
Maolat. Sn Chlorphen~sin
Maox. Sa Magn.sium oxide
maprotilin., 186t
MIr.R (m.:dication admini,tration
r<eord),88
mam'lirO<,530,
Maroain . Sa Bupivacaint
Marezin . Sa Cydizine
marijuana:
.ffu, 109
fetal . fkcts, 68,
toxicity signs. 106,
withdrawal symptoms, l06t, 109
Marinol. See Dronabinol
8B8
Index
Marplan. Sa lsocarboxazid
masculinization, 717
MAST CELL STAlIlllZERS:
,="
LibraryPirate
in hmlhcar~ facUities, 91
nursing p=ss in, 88--89
tracking,91
m~dication uror index, 85, 86/
m~dication reroncUiotion, 90
MEDMARX , 91
Mtdrol. Me Methylp .. dnisolone
m edro"YP ro8""t~ron~acdat~, 706,
action. and u ..s, 706,
administration alerts, 7061
ad..rr.. effls, 561., 706~ 707t
int~ractions, 706t
pharmacokinetics,706t
for sp<dfic conditions
cancer, 561,
dysfunctional ut~rin~ bl<ling,
707,707,
inj""tion for contraception, 697
MedWatch,87,91
mefenamic add, 228.
mdloquine,516.
Megace. See M~.trol
mellalobla,lic (p<midou.) anemia, 399,
M'
dru,
faclors aff'""ting, 40
m,""hani,m, lS/. 40
In olde r adults, 73--74
in pregnancy, 64"";5
Metaglip. Se~ Glipizidc/metformin
M.tamucil. Sre Psy llium mu cilloid
Meland .. n. Sa Methyltestosterone
metaproterenol, 132t
metaraminol, 132,
metastasis, 548, 548/
metaxalone,272,
rn<trrido .. inhaler (MOl), 591, 591/
m~tfo rmin,689 f
methadon~
MEGl.JfINIDE.\:
definition, 704
estrogen 10... in, 705t
hormone replac<m~nt therapy in. See
Hormone .. placc:ment thaapy
nalural therapy wilh black coho'h, 704,
menorrh"l!ia, 706
m~ notropin', 712, 712t, 719
M.nta>:. Sa But~nafine
me[J<ridin~, 222., 635
m~ph~nytoin hydroxyl .... , 81 , 81t
mephobarbital, 159',171,171,
meprobamat~, 159
mercaptopurine, 5so/, 554, 555~ 558,
M.ridia. Se~ Sibut"'min ~
meropen~m, 495~ 499
merozoit~s, 515,517/
Me""m N. Se~ Meropenem
m~salamine ,625, 6281
m~SGlline, 110, IIOf
Mf.<tinon. Sa Pyridosligmine
metaholit: acidosis, 420" 44 }.
IndH
LibraryPirate
mkafungin, 508,
Mkardis, SecTdmi.. rtan
Micatin, Sn Miconazole
miconazolt, 513" 514, 752
MICRhoGAM, Se< Rho(D)
immun~
~Iobulin
chrolllium, 649,
cobah,6491
copper, 649,
fluorbe, 649" 650
funcoon.,649,
iooino,649--5O, 649~ 662
iron, 399--400, 649,6191, Sa abo [roN
~
mangJneS<,6191
molybd~nnm, 649,
1189
imeractions, 3361
"""rdo.. t",atm~nl, 336,
pharm.cokin~tk.. 3361
route and adult dOst, 328,
mind--body int~rventions, 951
min .... l oil, 622, 6221
mineralocorticoid .. 670, 671
minerals:
macrominerals. Soc MACl{)MINIV.l.'i
micromin .... ls. Su )'lICROMlNlltM5
minimum effecti", concontration, 42, 43f
minipill .. 697
Minipress, Ste Prazosin
Minocin, Su Minocydin.
minocl"line, 489,
minoxidil, 3IS,
miosis, 770
Mio,tat, SIX Carbachol
M!OTICS:
649,
aoo
ANnM!GfJJNE DRUGS
propJ:ylaxis
btta - adr~nugic blockers, 2331
calcium cbanne! blocurs, 233,
methJ'S<rgid~, 233,
riboUavin, 2331
topiramate, 2331
tricydic amid~pr~... nt .. 2331
,;olprok acid, 233 ,
MigranaL Su DihydJ'Ort'gotamine mesylat~
Milk of .\lagnesia, See Magnesium
hydroxide
milk thhtl~, 96" 97t. 108,
milk--.an:a~ syndrome, 615
Milontin, Su Pb.nsuximide
Milopb.n~, Su Clomipb.ne
milrinOIl e, J36t
actior.. and u .... 336,
admimi,tration alal5, 3361
ad"" ... effects, 328" 3361
,arbachol, 770,
pilocarpin~ , 770,770,
MiraLax, See Polyethyl~ne glycol
Mirap<x. SIX Prami~lDle
Mi/'Crtt~,698.
Moban, Sn Molindon~
Mobie. Su Mdoxicam
modular formula .. 651
motXipru, 311,
molindone, 209,
molybd~nnm, 649,
momerasone, 580" 596" 760,
Monistal. Sec Miconazolt
monoamin~ oxidase (MAO), 130
MONOAMINBoxtru.IE INHIBITOl.\ (MAOb):
.dve.... df~ct .. 155" 156, 1&6., 189
druss dassifil as
iso<arboxazid, 1861
phrndzine, SIX Ph.nelzine
tranylcypromine, 155., 186,
imaaction .. 156, ISS" 189
mechanisms of action, 18S!. 189
Nursin g l'rocce.. Focu., Su
AntidC']l""sams, Nursin~ Pro.: ....
"""'
890
Index
(MASs):
ad"""", df.. ts, 458" 473
for amoimmun~ dioord~rs, 457
druss dassifil ...
al~mluzumab, 5631, 564
ba,iliximab, 457,458,
b..vadzumab,563.
hortfWmib, 563.
~tuximab, 563,
dadizumab, 457,453.
~rlotinib, 563.
gefitinib, 563.
gomlu:rumab o~micin, 563.
ibritumomab tiuutan, 563,
imatinib rntsylate,563., 564
intliximab, Su In(iximab
lapatinib,563.
lymphocyt~ immun~ globulin, 458.
muromonab-CD3, 4 57, 458,
rituximab,563.
ocinitinib,563.
soraf~nib, 563~ 564
tositumomab, 563.
trastuzumab, 563--fi4, 563.
m<'Chani,msof a<lio~, 4 57
for .~dfic conditior.
cancer chemoth~"'I'Y, 563--M, 563., 564/
immuno>uppression, 457, 453.
Monom. See lsosorbidr mononitrat~
Monopril See FminoprU
monosodium gluumat. (MSG), 230
monldukast, 596~ 599
Monurol See Foofomydn
mood disorder, 182. Set ~Jso Bipolar
disord.... ; Dtprasioo
mood stabUizers, 193. 5eealso Uthium
mominH skkn~... 628
morphln~ . ulfat., ll31
action. and uses, lllt
administration alul5, 223.
ad"""", dr.cts, 2221, 223.
H~n~tk polymorphis:ns afi'eaing
mdaholism, 81t
int~raclions, 223.
in mJ"'Xardial infarction, 35 I
"""rdo.. tn:atm~m,123.
pharmacokinetics, 2~3,
rouuand adult do ..; 222.
motion .kkneos. 577,621., 1\2'1
Motof~n. Set Dif~noxin with atropine
Motrin. Su Ibuprofen
moxil\oxadn, 491, 492, 492,
MarobU. See PI~rixaror
MSG (monosodium slulamatd, 2].0
mu n:cC'ptors, 221, 22 1t 221 .
Mudn.x. Set Guaif~n .. in
MONOCLONAL ANIl90DIE,
MUCOLYTICS:
act1ykyst";n~, 583., ,85
characteristics, 585
dorna .. alfa, 585
pharmacothrrapy with, 585,601
Mucom)"l. Set ~tykj"st~in.
mucosalaycr,607
LibraryPirate
mucositis, 552
Multaq. Set Dron.ru.rone
multiple tdaosi. (MS ):
characl~ristks, 266-07
classifICation, 267
di .....-modifyin8 drug.
immunomodulators
glatiram.rac .... at., 267, 267,
int~rf.ron beta- la, 267, 267.
interferon beta- Ib, .67, 267.
immunosuppressants
mitoxantron., 267, 1.67 t
indden~, 2.\6.
mupirocin,752
Murin. T.ars Plu . See T""n.hydrozoline
muromonab-CD3, 457, 458<
mus<arinic antaGOnist . See.
AN11QlOl1NJIGlCS
goals, 348
for symptoms and compliedt ions
ACE inhibitors, 350
anticoagulants, 349
antiplatdets, 349
beta-adren.rgic antaGOn.sts, 350--51
nitrates, 350
thromholylics.. Su TliROMOOLYf!CS
m}'Xardial i.m.mia, 339, 350/
m}'Xlonk ... i:rure, 168., 169., In
myoglobin, 349.
Myolin. s... Orphrnadrin.
MY.'lOlin . See Primidon.
mJ=<kma, 659., 662
definition, 508
incid~n~, 507.
opportunistic, 507
pathog.ns, 507.
pharmacoth.rapy. See Alo.T!FUNGAI..S
ruperflC ial, 507 ~ 508
syst.mic, 507., 508
Mycostatin. Su N)"tatin
Mydfrin. See PhnylC'phrine
Mydriacyl See Tropicamid.
mydriasis, 770
MYDRIATIc.\, 774, 774.
phen}"iophrin. See Ph ~n~krhrin ~
MyFortic. Ste Mywphenolat. mof.... il
N
N. ' . Su Sodium
nabilon., 629, 63(1.
nabum.lone, 228., 467.
N-a~tylcyst.in., 472t
N.a. See Sodium < hlorid~
nadir, 552
nadolol,I:J6~ 315., 343.
nafan:lin,712.
N.fcU. See Nafcillin
nafdllin, 484.
nalliflD . , 51 4.
Nallin. Set Naflifin.
N.HCO,. St. Sodium bk.rbon.l~
nalbuphin. hydrochlorid., 222.
Nalfon. Sr. F.noprofen
n.l ioi ixk Add , 4'11, 4'IIt
Indn
Naprdan. Su Naproxm
Naprosyn. Su Naproxm
naproxrn. 228,. 467t
naproxm sodium. 22&
naratriptan.2B,
Narcan. SN Nalo:ml1~ h}o:Iro<hloride
narcotk. 220. 221
narcotic analg~iC5. SN OP[OID (NAJtCO"I1C)
t.NAI.G<.S!C5
prnidllin .. SN
Pl:NICIllINS
LibraryPirate
ntphron.418.419f
nephrotoxic drug .. 4ID,
Neptaune. 51:. Methazolamide
ne"", agents. lID. 121,
ne",e bind:: anesthesia, 240;; 241,
Nesacaine. See Chloroprocaine
nesiritide. 328t. 334
Neslfn:. Sa Vitamin B,
Neulasta. SN Pcgfilgrastim
Neumep. Sn OprthdJn
Neupogen. Sa Filgr...,tim
neural tube defect .. 644,
neurofibrillary tangl.s. 263. 265f
nrurogcnk .hock. 407t
neurohypophysi .. 657
NEUIO(1N1N iECEl'fOR ANTAGON!ST:
aprepitant.629.63Or
ncurol.."tanalge.ia.248
nrurol . ptic mal;,;nant ryndrome. 187,. ISSt,
207~ 473
neurol.."tics, 206. Sre ~!SO ANnPSYUlOf!c";
NEUIOMUSCULU 1I!.OaE1.\:
d<p<>Jarizing
,uccinylcholine. Se. Succinylcholin~
as general anesth""i. adjunct. 252
nondepolarizing
miwcurium.252
tubocurarine. 252. 252t
Neuromin. Sre Gaoopontin
neuropathic pain. 219
Neutra-Pho .. Sa Potassium and sodium
pho.phor..
Neutra-Phos-K Se~Potassium and sodium
pho.phates
Neuttogrna. Sre Salicylic add
n ... irapine.53Ot
administration alerts. 533,
New Druglo.pplica tion (NO",. 6;; 7
Noxa,.,.r. Sa Sorafcnib
Nexium. Sa Esomeprazole
NF (Nmi<m~/ furmtlillry), 5. 6f
NHPO (Natural Health Products
Dirtctoratc 1. 9
Niac. SN Vitamin B,
niadn. Sre Vitamin B,
nkardipine. 307. 307t. 319
Nicobid. SaVitamin B,
Nicolar. Sa Vitamin B,
nicotine:
characteristics, III
offecr.. III
toxidty sign .. 106,
witlxlrawal .ymptom 106,
nicotinic add. SNVitamin B,
nkotinic receptors. UI. Ult
891
nif~dipin~,
308t
actions and u .... 307. 308,
administration alen .. 308,
am..... .rf.ct.. 233t. 307,. 308~ 708t
interanion .. J08,
mechanisms of action. 307
ovrrdosc trtatmem, 308,
pharmacokinetics, 308t
for ,~jfic condition.
angina and myocardial infarction.
343,
hyponrn,ion. J07,
migrain 233,
a. tocolytk, 708,
nifurtimox,521,
NUandron. SN NUutamide
NUlla!. Sre Nystatin
nilutamide.5611
Nimbex. SN Ci .. tracurium
nimodipin 233,
Nimotop. See Nimodipine
nisoldipinc. J07,
Nitro- Bid. Se. Nit rogly<:erin
Nitro-Onr. Sa Nitrogl)'<"cTin
nitrofurantoin . 495t
nitrogen mu.tard. 121,
NIJlI()(;EN MUSTAltDS. Sa ~Iso "UJ!A.l1NG
~,~
bc:ndamustin 555,
chLorambud~ 555,
cydophosphamid~.
51:.
Cyclophosphamid e
estramustine.555,
ifosfamide. 555t
mechlortthamine.555,
mdphalan.555,
nitrogl yce rin, 344,
action. and u .... 344 t
administration alm .. 344,
am...",dfcct.. 343t. 344,
interaction .. 344,
nursing proc ... foeu.
a ...ssm.nt. 344--45t
...aluation of outcome criteria. 346t
implementation
intervrntions and rationale ..
345-46,
patirnt and family..ducation.
345-46,
planning: patient goals and expecr.d
outcom . .. M5,
potontial nursing diagno .... 344--45,
m..,rdo .. trtatmem. 344,
pharmacokinetk .. 344,
route and adult do ... 343,
in "'-'J><CI<d myocardial inf."'tion, 350
Nitrop,""ss. Sre Nitroprusside
nitroprusside. 318t. 319
NitroQuick. See Nitroglycerin
NImOIOURfAS. Sa abo Mn!A.llNG AGElmi
carmustine.553.555t
lomustine.555,
strevtozocin.555t
892
Index
Nitrostat. Sn Nitroglyc~rin
nitrous OIid~, 2471
actions and u,"" , 247,
administration al~rts, 247.
ad""""d&cts, 2471
int ~ ractions. 2471
"""nlo.. t .. atm~nt, 247.
pharmacokinetics. 2471
nils, 753
Nix. Sn P~rm..thrin
nizatidin~, 6121
Niwral. Sn ~oconazol~
NOC (Notice ofComplian<C"),9
nockepti"" pain, 219
nociceplor, 220, 229f
Noct..:. Su Chloral hydrate
Nohad~x.
Sa Tamo.tif~n
ddavirdine,53O,
davi .. n7- Sn Efavi..,nz
..travirine, 53(1,
neYirapine, 5301, 5B
NONOPIOID ANAlGE..\!C.'i:
aCflaminophon. Sn At::rAMINOI'IiEN
centraUy-acting
donidine. Sn ClOllidine
tramadol,228,
ziconotid ~. 22S,
nonsteroidal anti-inflammatory
dru&S. &. NONSTIlIOII"-L
AN11- INFV..\'\M.o\IOlY DiUGS
(NSAlDs)
NONPHJ:NOTIl!AZ.lNO:
LibraryPirate
implemmt.tion
rvaJuation of outcome criteria. 211,
in~rvcntions and rationales,
211J.-ll,
patient and famUyeducation,
IllJ.-ll,
planning: patient goal. and cxpcctl
outcomes, 210,
potmtial nursins diagno""s, 209,
nOllspifk ceUularrcspon ..s. 50
nOll5piflc dden"" syst em, 447
NONSTEROIDALANTI- INI'l.AMMATOlY DRUGS
( NSAIDs):
drugs classified .s
ibuprofen and ibuprofen-like drugs
didofen.c, 228., 4671
difiunisal, 22Sr, 4671
otodola", 22SI, 4671
knoprofen, 228~ 4671
f1urbiprofm, 228 . 467.
ibupro&n. Sn Ibuprofen
indom ethacin, 2281. 467., 744
kctoprofen, 228., 4671
kctorolac tromethamine, 228,
mefenantic acid, 228,
mdoxicam, 228" 467.
nabumetone, 22S~ 4671
naprmm, 228., 4671
naproxen sodium, 22S,
oxaprozin. 22S~ 4671
piroxicam. 2281. 467.
sulindac,228,
tolmetin, 228t, 4671
salicylates
aspirin. Sn A.pirin
cooline saJicylate, 228,
saJsaJate,2281
scJ~C!i,.., COX-2 inhibitors
cdecoxib, 22S" 467t
herb--drug int.,..~'tion., 1001
mechanism. of action, 227
Nur,ing Process Focu,
assessment, BII
~.,.aluation of oulcom~critcria, 2321
implementation
intorvcmion.and rationales,
231 - 32.
patient and famUyC"ducation ,
231 - 321
plannin~: patient &
oal, and expccll
outcom es,231.
""tmtial nursing diagnoses, 231.
for specifIC condilion,
inflammation, 467- 70, 741
oSlroarthriti.,74 1
pain man.gemmt, 227- 29,
228.,741
u.. ~ .tatiSlic 465.
Non:uron. Sn Doxacurium
Norditropin. Sn Somatotropin
no"rinq>hTin ~ (NE), 411 r
action. and u..., 132., 411.
administration alorts. 411,
nAN>CR!!'fA.lE INHIBITOR>' S. .
~~~
abacavir.5>O.
didanosine, 5301
emtridtabine, 5>0., S38
lamivudine,53Ot
'iavudine, 530,
tenofoYir. 530 53]. 538
zidovudine. Sn Zidovudin.
Nu~n:ainal. s... Dibucaine
Nu~r""ine. &. Dibucaine
nur... (. ):
drug appro,.... l proces.s and, 9
al50
Index
nursing di~gnoses:
ddinition, 51
in dnIJ odmlnl~""tion, 51, 5&.
nuning proass:
defUlition, 55
in d"" odmlnl~ntlon
...wment p~, 55-57, 56r
cvalU<ltion ph.lIt, 59-60
anlibacterials, 496-98<
antichoiin. rilcJ (choiin.l"gk-blacking
agoents),1 45-46.
antico;!&uI~nU, 316-7'9r
antideprWilnls, 191-93.
antidysrhythmks, 361-63.
antkmdiCl, 632-33.
antifullpb, 5 10-12.
ant;p.ucolN dNiSo n2_73.
antit\Out drug" 745-16.
antihistami nes, 57&-80.
anti-inn.mmillorln, 473-75.
antin~laSllcs, 565~ .
518-20.
amipsychotlcs
atypical.2 1l-15.
con.-mliona!.21Q-11.
antipymkt. 41l-7S.
aotirctrovLtab. 534-36.
antise'izun: drugs, In_79.
anti,JWmodla, 276-n.
antithyroid agoenls, 668-69.
amitubcrculosis drup, 502-3.
bipolar di50rder therapy, 195-96.
bi.phosphonaln. 738-39.
bowel dl50rders, 626-27.
bronchodU.,on, 597-99.
aicium channel bIockrn. J09.--IO.
chonnerglcs (p;orasympathomimetiu ),
141-&3,
wlony-~imuLlllnB f3e1Qrs, 395--97.
diJaxin,332-33.
diuretics
hyperlm,lon, )05-7.
for ",nal failun:, 425-27.
ror
LibraryPirate
o
obftity:
elloioaY,63 1
object!Yc dlola, 5S
obttsJiYe-compubj", doordcn ( O<D ~ 150
Ocu gam, Sa lntra-,,:nous imrnWl~ globulin
oclr~ide, 624 ~
!42-141
HIV-AiDS p..... rma<OIMrapy. 534-36.
".....,
immunostlmu]ant.. 455-S6t
immunosuppn:JSOInls, ~It
,n",lil Ihctapy. 634-86t
levodopil or levodopa-a.rbidopa,
:<61-62,
lipid-lowering IhfU PY, 292-941
loca] . ne5,h.lie.!. 244-45.
nilro"yurln, 344-4&
non"~foktal ,lIlIj_innammatory drugs,
:il 1-32.
opiold In;tJanks, 224-26.
0011 hypoJI)'tOmk:s, 690-92.
O5I.lIOpOrosis and om... hoM di..,rders.
i3&-39.
oxyIo.:in.llQ-1 I.
pept ic uktr and autro..ophlgn/ ", Oln
di5<'IK Ihcrapy,613-14t
skeleul muscle n:iaunlJ, 276-77,
symp!Om~Iic cold ",Ii.r, 585-87.
thrombolyllcs, 384-115.
thyroid hormone ",plac.m.nt,
"'-'"
235-36<
660, 660.
dISlribution,73
= relion,74
melabolism,73-74
polyph2..mxy in, 90
pn:scrlptlon drugcmu and, 8,
oIillOmcnorrhe., 706
oligomeric formulas. 651
oIll1Ospam~
718
n4
tript~~s,
oIop.itadln.,575~
vasodilators. 320-22,
vitamin and min.ral pbumacOlherapy,
ols..l.zin., 625
omtil-3 f,uy acids. S Fioh oib
".....,
vitamin 1",401-21
nutritioaal Jupplcmmt'l'
.... t.ttI. S Entaal nutrition
indicl lion s. 650
!otaI9an:nlcral nutrition. S Toul
rlrtnleral nutrition
Nutropb. S. Soma,otropin
Nuv. Rin8,698
N}'lrazid . ~ hnnl.!zi d
n)'Jtatln, 5 15'
acliou and IISOIo. SIS.
admi.lstratlon alert .. SIS.
ad.-erlt tlfta, 5 14., SIS.
p/1;IrmiKOkinelk:s, 515.
routnnd adult dolt, 51 4.
Nyslcx. S N)'Slalin
N)'Stop. S N)'Slatin
Nytol. S Diphenhydramine
Bill
omepfiuoIe,6 11t
llClionnnd 113<'S,61 I~ 635
Onca5p<lr, ~e ~gaspargalt
ondlonse',ron. 629, 630.
opm-ansle ~l,uron .., 7611, 7611/
nphlh.lm!r <I,ul\"
adm lnistntion , 25, 26., 27/
.ntlglauco..... S ANTJGl.\l!CCW" [)1UG5
C)tloplcak$
a'ropine, n4,
dIIf'ilCtmSlIa, n 4
cydopentolau,
honull'OJ""', n 4,
n,.
894
Index
LibraryPirate
characleristics.688
nat.glinid~.687'
rtpaglinidt.687t
new.. ag~nt.
char""leristics.688-89
cx.nalid~. 687,. 688-89
prarnlintid 687 ~ 689
sitagUptin. 687 689
sulfonylurea.
charaeleristics. 686. 688
chJorproparnid~. 6871
glimrp;ride. 6871
g)ipizide.687.
glyburid 6871
tolazamide. 687,
tolbutamid 6871
Ihiazolidintdione.
charaeleristics.688
pioglitazone, 687,
ro.iglilazon 687.
herh--<lrug inl.raction . 100,
Nursing I'roc= !'oem
a ....sment.6901
.""Iuation of outcom. critrria.692,
implementalion
inl<rvrnlion. and rationale .. 690--921
patient and family.ducalion.
690--921
plannins: pati~nt goal. and rxp<aal
outcomes. 690,
pol<ntial nursing diagnoses, 690,
pharmacotherapy with. 683. 686
roule and adult doses, bl!/-8HI
Index
Orap. Se~ Pimozid.
Orap ... d. Se. Prrdnioolon~
Orazinc. Sa Zinc ""Ifat~
Or.ncia. Sec Abataccpt
Orgalutran. Sa Gani ... lix a"'t3t~
organ transplants:
frequency. 447t
"'j<"Ction.457
ORGAN!C NlnATI.S:
drug. dassiflCd a.
amyl nitriu. 343,
isosorbid. dinitra~. Sa lso.o mid.
dinilral.
ioosorbid. mononitrat 343,
nitroglycerin. SN Nil roglyctrin
m~,hani.m.of action. 341 -.4 2. 342f
nUllling process focus, 344-16t
rout. and .dult do .... 343t
;n <",!"c'M m~ni;.1 ;nfardkm. l'i()
therap<lltk approach. 341 -.42
Orinase. See ToJbutamid~
orli.tat.634
orph~nadrin 272t
Ortho Tri-Cyd.n.698t
Orthoclone OKT3. Sa Muromonab-CD3
Ortho- Cyd~n. 698.,
Ortho-Evra.698
Ortho-Novum 7f7 f7. 698t
Ortho-Novum IOJ ll. 698.
Orudi . See Kctoprof. n
O ... Cal 5((1. Sa Calcium carbonate
05fliamivir. 540. 540,
Osmilrol. Sa Mannilol
mmolality. 431. 432{
osmosi .. 431. 432f
mMOllC D1UIImCS:
773
m~chani'm. of action.
4211, 425
for spiflc conditions
sJ.ucoma.773
,..,nal f.ilu ... ,424. 425,
OSl.it;' ddo..man . See Paget', di ......
OSl"",nhriti. (OA ):
charact~ristics, 74 1. 7411, 741,
incid~n"'. 74 1,
natural therapy with glucosamine and
chondroitin. 743t
pharmacotherapy. 741
mi<oclast 731
osteomalacia:
caw;... 733
charact.ristics, 733
diagnmi 733
pharmacotherapy.733- 34
ollroporosis:
calcium m.tabolism in. 735f
~thnic/racial co",id.rations, 740,
indd'D<'~. 736t
lif~styl. consid.rations. 740,
LibraryPirate
pharma.cothr:rapy
bi,phosphonates. Sa B!'PHOSPHOOAThS
hotmonal ag~nts
caldtonin. 737. 739t
<in.cal"'t. 736,. 739
ralru:ikn . See Raloxif.n.
t:1"iparatide. 736,. 739
risk ["'tors. 735
otic preparations:
administration. 25. 26,. 27f
formulation.
..'''' tic add and hydnxortioon~. 776t
ber:zocain. and antipyrine. 776t
carbamide ~roxid~. 776t
cip:oflox..dn and d.xamethasone. 776,
cip",floxacin and hydrocortisone. 776t
polymy:Iin B. ntomycin. and
hydroconisone.776,
"ru.rmac.nth~'""l'Yw;'h. 77(,
miti. ,",dia. 480,. 775
Otrivin. Sa Xylom~ta70line
outoomts:
ddin~ion. 58
in dr~g .dministration. 58
o\"er -thHOUnler (OTC) drugs:
ad ..... age. and disad""ntages, 4
for oowd disord~rs. nausea., and
,"miting.634,
ddin~ion. 4
for gallroint. stinal disord~rs.
int ....actions, 614,
n .. di(ation ~rrors and. 91,
Oyidrd. s... Chorionic gonadolropin -
HCG
Ovr~tt~.698,
ovulation.695
oxacillin, 484. 484,
oxaJipl"in.555,
Oxandrin. Sa OxandroJon~
oxandrolon 717,
oxaproz:n. 22St. 467,
oxazrpan.157,
QlAZOllDlNONl'S, 494
linezolid. ~SL1 . 495 499
<m:arba;:tpin~. 169~ 173. 173,
ru:iconarole.513,
OxistaL Set Oxi<onarol~
oxybutynin. 143.
oxycodon. hydro<hlorid~. 222,
oxycodOlletOT~phthal.t~. 222t
OxyComin. Sa Oxja>don~ hydrochlorid.
oxynl <1, ro lin 5821
actior.sand uoes, 132,. 582.
admiai'tration alOTts. 58.2t
ad"""" eff<"Cts, 581,. 532,
int.ractions, 582,
pharmacokinetics, 582,
for specific conditions
nam decongestion. 581,
ophthalmic irrit.tion. 774,
oxynlorphon. hydro<hlorid~. 222t
QlYTOC!a:
defin~ion.
707
895
drug. dassifird a.
carboprost trom~thamin~. 70},.
704.708,
dinoproston 7031. 704. 708,
~rgonovin. maleat 708,
m~thyl.rgonovin~ maI.at 708.
mi5Oprostol. 617. 703t. 704. 708,
oxytocin. &. Oxytoci n
oxytoci n,709t
action, and uscs, 708--9. 709,
administration al~ns, 709,
ad.... ""'dkcts, 7081
function 708-9.709f
iDlOT""tions, 709,
Nursing Proces, Focu,
..... ssm.nt. 71O'
evaluation of omwmc"iIOTia. 71 It
impl"", . ntation
;n'~T\"en,ion< .nel .... ion.I ~_,. 7t t.
pati.nt and familyrducation. 711,
planning: pati.nt goals and expt~d
outcom~s, 710.
pot~ntial nUllling diagnoscs, 710t
"""rdo.. t .. atm~nt. 709,
pharmacokin~tics, 709t
rout. and adult do ... 70S.
secmion. 658f
P
p53 gm 549
paceJ1"laker.356
Pa'OTon . Sa Ami odaro n.
Pa,ific~.
559
.. Ikylat~.
aspirin. See Aspirin
cholin~ salicyJau. 228.
salsaJate.228,
tramadol.228.,
palliation. 550
palonooetron.629.630,
896
Index
Pamdor. Sa Nortriptyline
pamidronau, 736.
p-aminob.nzok add (pABA), 763
Panaxgi""ns. Se~ Gin ... nE
I'Ilnaxqu;nquefoliu . SeeGinsmg
panc~a.s, 679, 679f
Pdnu~ ... See Panc~1ir ..... e
panc~atk enzymes:
ilctions wd US<"i,633- 34
drugs classified as
pancreatin, 635
panc~lira",. Sa Pancre lira.e
panc~atin, 635
pancr.",tit;':
acute, 635
chronic,635
pharmacoth.rapy, 635
p.ychosodal and communily impact.
635,
panertli r a .., 6361
actions and u ...s, 636,
administration a1erl .. 636,
ad,..,,,,,, effects, 636,
interactions, 636,
O\.."doS<" malmenl. 6].6,
pharmacok.in~ic.. 636,
pancuronium, 278,
panic disorder:
deflnition, ]50
pharmacotherapy. 154- 55
pantoprazole, 611,6] I.
pantothenic acid (vitamin 8,),640,
papa""rine,721
Paracmldohyde. Sa Paraldehyd e
P.. rafl<x. See Chlor7OXllZOne
parafollicular cell., 66]
Parafon Pone. Su Chlorzoxa70ne
paraldehyde. ] 59
paranoia,204
Paraplatin. See C;'platin
parasitk infections:
childhood playamls and, 5231
lice. S.. Lice
scabies. Sa Scabies
parasympathetic nermu, .ystem,
128-29, ]28f
PAlt.\..YMPA11IOM!MEI1a. See CHOliNERGICS
parathyroid gland, 73],73]f
diphenhydramine,577
dopaminergics. See DoPAMINERGICS
mc:chanism, of action, 259, 25\1f
Nursing PlOCe5S Kx:us, 261-fi2.
P.rlodd. Sn Bromocriptine
Pamate. Su Tran}"icypromine
paromomycin, 490, 490~ 521.
pamutine, 155" 1S6t
Pdr""I, 763
partial a80nist, SO
pania! (focal) seizure, 167, 168~ 169t
P.ser. See Aminosalicylic add
passi"" immunity, 449, 451 f
passi.., transport, 37
P.tana .... See Olopatadine
Patanol. See Olopatadine
pa~n, 479
pathogenicity. 479
patient and family education:
acne, 758-59,
ADHD and ADD pharmacotht-ra py,
199- 200t
ad~nergic agonist. (sympathomimelics),
1>4- 35,
adrtntri;ic antaitOnim (sympatholytics ).
138- 39t
androgen., 720-21.
amian~mic agent .. 4021
antianxiety therapy, 162-fi3,
antibacttTials, 496-98t
antkholinergks, 146,
anlidepressants, 191 - 93t
antidysrhythmics, 362-fi3,
antiemetics, 632- 33.
anliglaucoma drugs, 772- 73t
antigoul drugs, 745-46,
antihistamine .. 578410,
antinwpiastics, 566-fi8,
antiplatdet agent., 381-$2t
antiprotozoal. and anlihdminthks,
518- 20t
antipyretic5, 474-75t
anti .. izure drugs, 177- 79,
anli'pasmodics, 276-77t
antithyroid drug . 66iH'i9.
antitub.rculosi. drugs, 502- 3.
alypical antip.y<chotics, 21 4-15.
bipolardi""rder ih<rapy, 195--96.
LibraryPirate
",-",
immunoNpprtisam., 460-611
insulin therapy,684--86t
lemdopa or levodopa with anbidopa,
261-fi2.
lipid-l""..,ring therapy, 29 3-94,
local anesthelics, 244-45,
nitrog]y<cerin, 345--461
nonsteroidal anti-inflammatory drugs,
231 - 321
opioids, 224--26.
oral hypogly<:emico,690-92,
05troporo,;' and other bone disorders,
738-39.
oxytocin, 71 I,
peptic ulcer and ga.tro.-oophagealreflux
di ...... therapy, 613-14,
sulml muoclt ,tJaxants, 276-771
.ymptomaticcold rdief. 585-87.
thrombolytic., 384--85.
thyroid replacement th.rapy, 668--69.
vaoodilators, 320-22,
vilamin and minerdl phamlacotherapy,
"'-',,
definition, 753
drugs classified a.
lindan~, 755
mal.thion, 753
permethrin,753
pyrethrin,753
Nursing Proce .. !'oeus
a ..... ment, 754,
evaluation of outcome criteria. 755.
implementation
intrr\"ention.and rationales, 754- 55t
patient and family education,
7~4-5"
Index
~gfllgra'tim,
391 ~ 394
alfa-2a, 454., 542.
~gimaf""m a1fa -2b.454., 542.
P~g- lntron. Su Prgintaf~ron alfil- 2b
PEG-L-a'paragin ..... SN Prga'parga'"
~gvisomam, 660~ 661
~gylation, 542
~gin!afaon
~Uagro, 643
PIm Tscw, 3
~nddovir, 538.
~n~trat~calcium
trisodium, 123.
trisodium, 123.
~nidlaminc, 123.
~nkillin G b"nza!hin~, 484.
~nkillin G procaint, 4S4t
penicilli n G sodium/potassium, 4861
action, and u ...s, 4861
administration al~rt" 486.
adY~r ... dJcet" 484" 486,
ima.ction',486t
pharmacokin~tk., 486t
rout~ and adult 00.... 484,
penkilUn V, 4Mr
~nidlUnase, 484. 485f
~nkiUinasc-resistant ~nkiUins, 484, 484 .
Su a/s" P!N1C1LUN.
~nkiUin- binding prot. in, 484
~n .!ra!~zin"
PE.NlOLLlNS:
(am ipseudomonal)
caro..nidllin, 484., 485
charactaistk" 485
pi~raciUin sodium, 484; 485
pi~racillin lazobactam, 484,
IkarcUlin, 484t
natural ""nkUlin.
pmicillin G Mnzathin~, 484,
pmicillin G procain~, 484.
~nkillin G sodium/potassium.
Set ~nkillinG so dium /
potassium
penicillin V, 484,
pmicmina ... -ro.istant
charact.ristics, 485
cloxadUin, 484, 484,
did""""min,484,
nafcillin, 484.
oxadUin, 484,484.
m~chani'm. of aClion, 485
pharmacothtrapy with, 485
rout~ and adult do .." 484,
P~ nlac. Su Cklopirox olamin~
LibraryPirate
Pentam. SN P~ntamidin.
pentamidin.,521.
Pentasa. Su M<"SaIaminc
J><ntalOdn~ hydrochlorid~,
221 ,
all. 222.
pharmacokin~tics, 753t
Penthran~.
Su M<1hoxyfl.uran~
pmtobaroital sodium:
as sc""ral anesthesia adjunct, 252t
for ... 4iuion wd insomnia, 159.
forscirur." 171.
Pentolair. Su Cycl"P"ntolal.
Pentostam. See Sodium .tibogluconal.
~ntostatin, 555.
Pentot .... l. Su Thi op< ntal
J><ntoxilyllin., 375, 379., 380
Pen- V~. K. Su P~nkiUin V
Pepcid. SN F:irnolidin.
I'rplamm Liquid. 651
J'qIUC ULel" di .....-:
ddln~ion, 609
~rrnitil.
See Fluphenazine
(m.-galobla.tic ) an<rnia . 399,644
~miciow
~rph.nazin.:
iKEI'IOR ANTAGONISTS
897
Per~222
pharmacology:
d.finition,3
history, 3
y. th~ra~utic>, 4
pharmacopotia,4
pharmacoth.rapy. See ~151> Drug
admini'lration
community and enyironm~ntal
influenu .. 79--80
cultural and ("[hnk influences, 78-79
d.finition, 4
g.nd~r influ~nu" 8]
8.n~lk influences, 80--81, 8],
holi.tic. 77
psychosocial inlJucnc~" 78-79
PwroN
lUMP INHIBITORS
sucralfutc, 616
thcraprntic approach, 609--10
risk frctors, 609
symptom,,6JY)
Pepto- B:Smol. See Bi,muth ",b.. licylat.
89 8
Index
Pharmacotb.rapy UJustr-~ted:
activ~ and passi..., immunity. 451f
Almrimd. dis<:a"" drugs, 265f
angina drugs, >42f
antid~p",s .. nt therapy. IS5f
antihypert~nsiv~ drugs, JOlf
antiparkinsonism drugs. lS"If
antispasmodics, 274f
antiulur drugs. 610{
htnign pro'tati< hyperplasia, 726/
cholestmll-lown'ing agrots, 289{
corticosteroids (glucocorticoids) and
ad"'nal atrophy, 672/
diu",tics, 421{
GABA rre~ptor--<hlorid. channd
mole<uI. ,170{
heart failure drugs, 327{
limbk system and reticular ""tn'.ting
syst~m,151{
'M,
".
Pharml'acl>:
ahmati..., th~rapies, attitude. toward.
ane'th"ia and an.sth~tics. 242.
angina, 340,
anxiety disord~rs, 1511
arthriti .. 741,
a.thma, 591,
attention def"'it-hy~r""tivity disord~r,
,,,.
canur, 5481
dotting disorder .. 3711
community health 5tatistics in the
U.S., SO,
d~g~n.rati"" distases of the central
n.rmu, syst.m. 256.
d.p", .. ion. IS3,
diabtt~. mellitus. 680,
dysrhythmia .. 3551
.pil.psy, 168,
femal. r.productive conditions, 6951
f.taleff~cts of drug uoe during
prognancy.68,
fungal infection 507.
gastroint ~stinal disorders, 621 ,
glaucoma. 769,
,ra~fruit juke and drUJ, interactions.
".
LibraryPirate
m)'Xardial infarction,.l4Q,
orpn transplants. 447.
ost.oporosis, 736,
pain, 219,
poisoning,711
prescription drugs
consumer "",nding, 5.
marming costs, 14,
time length fur FDA appro",l, S,
protozoal infrctions. 5071
psycho""s. 204t
r.nal disorders. 418.
.<hock, 406.
skin disord.rs. 751,
St ...,no--Johnson .yndrome. IS.
substanu abu ... tatistics. 14., 1041
terrorist mach, polential chemical and
biologic agents for. 116.
thyroid disorders. 6621
tox", tpidermal nrerolysis, 18.
upper gastroint"tinal trad disorders,
"".
vacdnes, 447,
viral inf. clions, 527,
vilamin~. minerals, and nutritional
supplement,,639t
pharyngitis, 480,
Ph~nazine.
Siie ~rphenazin~;
Promethazin~
ph enelzine, 190.
actions and ...... 190.
administration alerts, 190,
adv~r...ff.d .. ISS., 186~ 190t
interaction lOOt
overdo"" trratment, 1901
pharmacokinetic.. 190.
route and adult do ... 1551
for specific conditions
anxiety symptoms, 155,
dep"'ssion, 186.
Phenergan. s"., Promethazine
Phenergan with Codeine. 584.
phenindione.67.
ph enoharbital,I 721
actions and U""S, 172.
administration alerts, 172,
adv~... effts,67/, 159t, 17lr,I72.
interaction I72t
Oy~rdo .. trratment, 1721
pharmacokin etics.lnt
route and adult do .., 159.
for spedfic condilions
sedalion and insomnia. 159.
..iru",.. 1691, 171. 171.
PHENOTIlIAZlNIS:
pb.ntermin 634
pb.nlolamine. 136., 721
ph~nyl "l' hrine, 13JI
actiOn! and UIO. 132" lBI
administration alert.. 133.
ad...,r .. dfects, J33~ 409t
in cold/allergy combination drugs, 5761
interactions, ]33.
oyerdosetreaunrnt.IBt
pharmacokinrtk., l331
fur specific conditions
e)'l' irritation, 774. 774 t
nasal congestion/allergic rhinitis,576,
576t, 581t
shod::. 409.
pb.nylpropanolamin e. 634
Pb.nytek. s"., Ph ~nytoin
ph~nytoin, 1751
action. and u .... 175.
administration alert .. 175t
ad...,r.. dfrcts, 173~ 175., 360.
interactions, 175/, 187t
o..erdo""trratm~nt. 175t
pharmacokinetk., 1751
for specific conditions
dysrhythmias,360.
seizures. 169t, 173,1731
PH' NYJOIN- IlKE !.GENTI:
Carbamazepine
174
lamotrigin . See lamotrigin.
valprok acid Stx Valprok~cid
zonh,amide. 173-74,1731, 175
phobia .. ISO
ph",ge n~ oxime, 12],
I'hosLo. Siie Caldum aulal~
phosphodi.ot~ra"", 335
f<lbamat~,I73I,
PHOSPHODl~
lNillBITORI:
IndH
and rationales,
723- 241
patitm and family education,
723- 24,
planning: pati~nt soaJsand exptct~d
outcom"',711t
potential nursing diagnoses, 723t
Phospholine Iodide, &e Echothiophate
iodide
phosphoUpids, 283, 2Mf
phosphorus/phosphate:
functions, 648, 648,
imbalances, 4371, See. at.o
Hyperphosphat~mia;
Hypophosphatemia
for nutritional and d~<lrolyt~ disord~rs
monobasic potassium and sodium
pho,phate ,6471
monobasic potassium phosphate, 647,
potassium and sodium phosphates,
..."
LibraryPirate
1'1..\.= ENHANCEIS:
drugHla .. ifled as
t1trombopag, )911, 397
opJ~h;ekin, 391t, 397
romiplostim, 391" 397
pharma.coth~rapy with, 394, 397
Platinol.Sn Ci.platin
Plavix. SocClo pidogrd
Plendil. See. Fdodipi"~
pkrixafor,564
Pletal. Ste Cilostazol
pneunto.:OC<al infections, 47<;1,
pnewnooxcal vac.;in .., 4 52t
f'!1""m",,"~ 480t
f'!1eum,,:v,,;, carin;; (PMumocysrk prowd),
,07,
pneumonia, 4SOt
Pneumovax 23. Sn Pnrumococ<al vac.;ines
pNS (peripheral nervous .ystem), ]27, 127/
plJdophyl1~m peI""um, 559
poisonir_B:
inddrnce,7],
iron, 70.
prev01ltion,69
top 2S substance. invotv.d in, ]22,
t ... tm~nt fundamental., 12t- 22
Poladex. Su DexffiJorphrniramine
Polararnine. &e D=hlorph~niramine
polariztd,358
poUo',ins, 1]9
poliovirus ""ccine, 452t
Polyco .. , 65]
polyc:thllen~ glycol, 622t
polymeric fommla, 65 I
polymyxin B, neomy<in, and
hydroconisone,776t
polypharmacy, 73, 90
pol)'Styren~ sulfate, 420t
polyviJl}1 alcohol, 774.
Ponstel. & ~Mfrnamk add
Pontoca.n . Su Tetracain~
899
P",;';or. Su M~fradil
positi..., inotropic a8~nts, 325
positi..., symptoms, 204
posteriorchamber, 767, 767/
POSTIlIIOR PfI1JlTARY AGENTS:
d~smop", .. in. Sn D""-lno pr .. sin
Nur.ing Pro<..s Focus
as ...smont, 665t
cv;a/uation of outoomc criteria, 666t
impl""'~ntation
drugs classified as
amiodaron~. Su Amiodarone
doktilide, J60t,.l64
dronedaron~, 360" 364
ibutilide, 360t, 364
sotalol, 3601,.l64
mechanisms of action, 358f
pharmacotherdpy with, J.63--6t
potassium chloride (KO), 4391
action, and uses, 439,
administration al~ns, 439,
ad.,.."" df~ct .. 439., 647 t
interactions, 439,
ion,, 4J.6t
"""rdo.. treatm~m, 439,
route and adult dose, 647t
potassium iodide {KIl, 120--21 , ] 23.,
650,667
potassium ion dtannds, 358, 35Sf
potassium and sodium phosphat.., 647t
POlA.I'IIJM- SPARlNG DlIJIIETICS:
900
Index
(amL)
faUu",. 32&. 329
hyptrl<nsion. 302,. 3031. 304
",nal faUu",. 423. 424,
potency. 48--49. 48/
PPF. St. Pla,ma prot~in fraction
pralidoxime.IDI
pramiP=lI~. 257. 2581. 259/
pramlinlidc.689
pramoxin 242,
Frandin. S Ropaglinid.
prasug"'l. 3791. 380
FranchoJ. St. Pran'lalin
pranstatin.287,
praziquantd.522,
pnlzosi n.137,
Jctions Jnd uses. 1361. 1.l71
administration a1~rl .. 137,
ad,..,,,,,,./hcts, 1371. 315,
classification. 13fu
int.ractions, 137,
",..,rdo.. trtatm~nt. 137,
pharmacokinetics, 1371
for s~dfic condition.
I'OTA.SSIDM- SPARING DllJRFllCS,
h~art
btn~n
hyptrtension. 315,
fucia. S Dtxmod.tomidin. HCl
preclinical inVC":'ltigation. in drug
deyelopm~nl.6. 7/
fuco ... SN. Aalrbo ..
pmlnisolon 470.. aI,
predni so ne.U I,
action, and uses. 471,
administration a1~ns, 471,
ad"""", dft" 4701. 471,. 561,. 671,
int.ractions, 471,
pharmacokinetics, 471,
for 5~dfic conditions
"d..noconical insufficioncy. 671,
cancer. 560. 561,
intlammalory bowd di .... se. 625
intlamrnalory disorders, 470,
fukst. St. Estradiol/norg~'timat.
pregabalin.169,. l7I,
preganglionic nruron.129
pregnancy:
antisei Lur~ drug, during. 167
oornplications, 167
d~p",<";,,," "f'~r, 1~}
drug r~gi.'ries, 66
FDIo. drug cat.-gori. s, 65-66. 6fu
folic add supplem~nts in. 3991. 644,
gestational age and dru~ therapy. 6,
patient teaching about drug th.rapy
during. 68
pharmacokinetic, during
absorption. 64
distribution and mdabolism.64--65
=""ion.65
pharmacological agents for <"arly
termination
carboprost trometham in~. 7031. 704
dinopro,'on 7031. 704
LibraryPirate
P"'pidU. Su Dinopro,ton<
p",,,,hool child. 70. SN. abo Child.. n
P",scription Drug UKr Iff Act. 61. 8
p",scription drugs:
abll5C. lOS
brand -name .... generic equi\"lll~nts,
13--14
consumer spendillion. 51
di,~nsing. 4
ffect of costs on okl~r adults, 8,
marketing and promotional sp<nding.
",
J.6O'.
7071
<strad iol/dro'pirenon 707,
estradiol/n0'1l"51imate.707,
~thinyl ~stradiol!norfthindron~
acetat~,
7071
M. d roxyprogcsteron. """t.'e
no",thindron 698~ 7071
progest.ron 707,
functions, 695. 706
Nursing Proce.. Focus
a ..."ment.701,
implem~mation
Indn
propofol,251t
propoxypt.tM hydrochloride, 222l
p~ napsylilte, 222,
propranolol, )6.tf
lClionnnd "SfS. 136, 1361, 364.
;adminisl",tlon :alttts,3641
;ad...,nt dfKU, 1601. 2)31, 31St. 343;
l6Ol, )6.1,1
migraine, 2331
propric!.1ry ( m,de ) IIiOnlC, 13. ~~..Jso
Brand-name dmgs
propylthi ouracil,6671
actioDi . IId uses. 664, 667,
administration aleru, 6671
advent dfKIi, 6631, 6671
interactions, 6671
o""rdost lIutment,6671
pharnt;w;:ol;lnetk:s, 6671
mute and ;adult dose, 6631
Proquad,4521
Prosar.Su Fi" . ste ride
Prosom. S EstazoAm
PlKJSTAC.l.ANDlNS:
functions.217-28
mKhartisms of action.. 4651, .c67
fGr ~ilk conditions
as emergency contraception, 703.
.Jauroma, 769, 770/
pha.macologlc~1 abortion, 7031
as tocolytlcs. 708, 7M.
p""tate. S Iknl. n prostotic hrpertroplty
Prostigmln . S NeoSliQmine
Prostln E,. ~(Dinoprostone
prot.mlne :sulfate, 123" 375
protealt,528
I'ItOTTASE tNlUlitlOltS. S.
Nml.lnOVllALio
LibraryPirate
daroruovir, 5301
I'osampunovir, 5301
indinavlr,S301
IopiMVi.!litonavi . s
lopi,uvir/ rilooavir
ne13D<1vlr, S30f
rilolUvlr, S30~ 537
saquinovif,530t
tlpml~vlr,
530t
dru8'wssitloed OS
aomeprnole, 611, 611.
I;!ruopr.IZOIe, 611
omepruole, See OmeprolZOle
p.>r.lOprazoJe, 611,611.
robtprnzole.6111
n>edunlsms of .clion, 610/
NUl1bgl'rocess Focus, 6]3--1 41
pharmil)th~ ... py With. 6] I
Pmtonb:, Sa J>~nlOpruol~
ProIOPUI, S Prali<kWm~
ProIOpk. See Tltcrolimus
pMOIy!" drua. 12
pnMo-.Sl5
pfO(OW,&J lnfKtiOf1s:
incidence,5IJ7/
malolti;t. S MaI~ria
nonmaiarlal,S21.
prot.ipMlnc, l&a., H31
Pro""ntil, S Albuterol
Pro""ra. ~e Mcdroxyproge. tcronc acd~tc
provita.mlnl, 639
ProU(. ~e Fh,lORtiM
prurll .... 7SO
Pnusian blUl', 1231
p$UdocphedriM:
actior., and U5<.'J, 1321, 133
itt ODr:tbination ooIdIallergy drugs, 576.
metlt.unpheiamiM abu"" and, 58]
for nar.Il dKO/18estion, 581.
pseooomembr.nolis colitis ntibiotic_
anGelatN, 494
Psn<dc>"'-Or'<lS """,gl,.,u., 480., 4S1
ps;iJOC)'bin. IW/
p50nolens, 763
p$Ot'iash:
cha ... "erlstkl, 760, 76]/
dt\l8flrlggerin&.76 1
rtloloiy, 761
nonpUntlilCOlogicallherapy, 763
pharmKOlhelllPY
.,..mk
KiIMin,7621,163
adalimllmab, 7621, 763
901
'"
purine, S~
PVlINE .o.NALOGS. S . ANTlMEl'AIIOUTlS
cbdtiblne, SsSt
dGf~r.bine, SS51
fi\ld.:lr.bine,5S51
5551
j)('ntostatin.5551
thiogu<lnine, S55~ 556f
Purklnje ftben, 356, 356[
push ( IV bolus ) odminiit",tion, 32, H/
push pltaage, 113
pwlU];Ir ptOritiis, 76lr
py"'ntc~ 522" S13
pyrulnamide, SOOt
pyrtthrin.. 753
pyridost.i.m'M,IJY,I4U.
902
tndex
pyridoxine. SuVitamin
516t
pyrimidin~, 554
S.
pyrimethamin~,
ANr!MEl'AOOLITES
ca""dtabine, 555,
c)'larabine, 5>0[. 5'4,555.
Ooxuridine, 555,
nuorouracU, 5SO{, 551, 554, 555,
g~mdtabine, 555.
pZt\, See Pyrazinamide
Q
quazepam, 157.
Qudicin, See SUc<in ykholi ne
Questran, Su Cholestyram ine
qudiapine fumarale, 194~ 213r
Quin.mm, S.. Quinine
quinapril,328,
quinidine glumnate, 360r
quinidine sulfal<, J60r
quinine,516t
quinupristin--<lalfopristin, 494, 495t
Q""r, See Bedomdha'lO n.
R
rabeprazole, 6]],
rabi~s immune globulin, 450r
radal wnsideration., Sf< Ethnic/radal
consid.r~tions
LibraryPirate
system:
in Huid balance, 432
",nin--an giot~ nsin-aldosteron e syst<1l1:
characteristics, 3 H'- II, 3 tof
drugs affrctin8, &e ANGIQTIN,IN II
ll=R BLOCKElt\; ANGIQTIN,IN-
Repron~x. Sa Mrnotropins
lkquip, Sa Ropinirole
Rescriptor, Sre Delavirdine
Rescula, &. Unoproston~
Resear<h Shows:
alt~mating dose. of ibuprofen and
acetaminophen for child"n, 4 Ht
folic add supplem~nts prior 10
pr~8nancy, 399,
HIV testing, influences on, 529.
lipid-lowrring therapy in diabetics, 683,
mediaotion errors in child",n, mosl
common types, 9 II
mwiaotions for <hikl .. n with chronic
cough,584,
substance abuse and ..dentary lif~style,
to5r
_ight loss strat~i.., 635t
"serpine, 315,
r.sistance, 48 1-82,4S2f
respiration, 590
=piratory acidosi" 44 I r, See "Iso Adooli.
",.piratory distress .yndrome (RDS), 601,
rest-and-dig<'Sl "'sponse, 128, 12gf
Restora, SfeTemazepam
Reta,,,se, See lkt'1'l.se
""'1'I...,351r
actions and uoes, 351,
administration alerts, 35 I,
ad""rse dfe<ts, 351., 383,
interaelions,351,
pharmacokinetics,351.
route and adult dose, 383,
reticular activating sysl<m (ItAS), ISO
reticularformation, 110, ISO, 151f
lktin-A, See Tretinoin
llETINOIOS:
characteristics, 756
drugs classified as
adapaLen~, 756, 7561
isotretinoin, 756, 756,
t"'tinoin, See Tretin oin
lktrovir, See Zidovudine
r...."'" ,holesterol Iran sport, 283
rn'e ... lranseriptaS<', 52S
l=~ TItANSCIt!l'fA,E lNH!I!ITOIS,
-~~
IndH
LibraryPirate
5
SA [sinoatrial) nnde, 356, 356/
SAD ( ~ISOnal affectM disoroerl, 182
SaiLen. ~n Somalotropin
SalOL S", Salicylic add
SAL!CYLIIT.S, 468, 741, 763
a.piri~. &e Aspi rin
choline .. licyla". 2281
salsa],te, 228,
salicylk acid, 7621
salicy\i~m, 468
salmeterot, 5951
actior.sand u .... 1321, 593, 595,
admimistration alem, 5951
ad,.r.. rffects, 594" 595,
interaction .. 595,
overdose t .. atmrnt, 5951
pbarmacokinrtks, 595,
routrand adult dose, 595,
752
characteristics, 753
drugs da .. ifi..d as
(rotamiton, 753
lindane. 755
penn~thrin. See ~rmrthrin
Nursbg Proce .. 1'ocu.s
a"''''m~nt, 754,
evaluation of outcom~ crilrria, 755,
implrmentation
int .....entions and rationalr ..
754-55,
patient and family ..ducation,
754-55,
pla~ning: patient goal. and upect..d
outcomes. 754,
por.ntial nursins diagnoses, 754,
903
pharm.cotherapywith,753
scabies:
charact~ri'tics, 752, 752/
pharmacotherapy. See ScABICIDES
psy<hosocial and community impact,
755,
sch..dulrd druSS:
Canada, 15,
definition, 14
U.S., 14, IS,
ochizoaffective disorder, 205
ochizoph.. nia:
definition, 204
pathophysiology, 204--5. 205/
pharmacotherapy, 205~. &e al5c
ANrIPS'lCHUJ1CS
'"
904
Index
"';zu",.. (am,.)
(SERMS):
characteristics. 562, 737
drugs d ..,ifir<i as
ralru:ifene. Se< Raloxifene
tam""ifm. SN Tam""ifen
to",mifene, 561, 561,
for 05leoporosis. 737
S=VE SEROlOOIN n:tWfAXE INHIBITOR'>
(SSRIs):
adw"",dfrcts,155,. 156, 1861,137,472
drugs d ..,ifii as
dtalopram, 155t, 186t, 266
dtalopram oxaIatr. SN EsdtaJopl""dm
""alale
tluantine, 1551, 186t, 266
tlm"Oxamine, ISS" 186t
paroRtin. ,155t.l&&
... rlTaline. See S.rt l""aline
.ibutramin . Su Sibutramine
herb-<lrug inleractions, 1001
m<"<hanism.ofaction, 184, ISSJ.
186J. 137
Nursing Proc<:.. Focu . Su
"nlidq>ressants, Nursing Pro<e..
Focm
for .~dfic condition.
anxirty,
n .., and d.p", .. ion,
155t
depre..,ion, 186" 187
obesity, 634
.. Iegiline hydro<hloride, 257, 258,
.. Ienium, 100" 549,. 649,
Sdzmtry. Sn Maraviroc
.. niorcitiuns. Se< Older adults
.. nna:
~d"" .... dfecu. 622.
drug interoctions, 175" 471 ~ 673,
m<"<hanism. of action, 622
route and adult do ... 622t
s<:nolroL Se< S<:nna
Sen,ipar. Su Cinacalcrt
.. ntind event., 118
",ptk shoo:k, 406. 407,
"'pti",mia, 480t
Seplodont. See "rtkaine
Septra. S.. Trimet hop rim ul fameth o:<aZO Ie
Serax. Se~ Oxazepam
5rt"...ent. Se< Salmetero l
SElU.t S. Set S!llECl1V[ ES1l!O(;EN- RECE!'fOI
"'.il....
MODlFlEb
LibraryPirate
See tilio
U"',
pathophysiolo8Y, ~07f
pharmacotherapy
eff<ets, 4071
fluid replacement agents. SN flUID
-,
Index
n~plastk,
750,
para,ite., s.., Lia; &abie.
pooria.i., Sa Pooriasi>
rosac"", 757, 757/
interrdatiomhip, with other body
.ystem., 751/
layers.750
s.leep:
functions, 152
.tages, 153, 154,
s.leep debt, 153
sIping .idrness, 521 t
Slo-Mag, s.., Magne,ium chloride
SJlla!lpox, 119--20
,moking, s.., Nicotine; Tobacco US<'
SNRls (SrROI'ONlN- NOlPlNEPHRINE
~~uym:'INH!!rroll), 186r, 188, Set
alsc A TYl'ICAL AmID!:PI!!'5SI.NTI
,~NS (StT"'~Bk N",;on~1 Stod"n~),
t til
social anxiety, I 50
sodium (Na'):
functions, 64g,
imbalanct., s.., HYP"matremia;
Hyponatremia
in myocardial cflls, 358
pharmacotherapy with, See Sod inm
bicarbonate
recommended dietary aUow.nct, 648,
rena! regulation,423, 437, 438/
sodium bicarbonate (NaHOO,), 44lt
actions and uses, 441,
administration alens, 44 I,
adyerse dfeds, 441 t, 647,
for aspirin ",,,,rdose, 41, 122
interactions, 441,
ions, 436,
overdose tmllment, 441,
pharmacokinetics, 441 t
route and adult dose, 647t
for spociflc condition.
acidosi 440, HI,
a. antacid, 615t
nutritional and electrolyte disorder.,
647,
sodium biphospltate, 622t
SODIUM CIIANN.L BI.OCKDS:
drug, classified a,
disopyramide phosphate, J6(Jt
fl=inide, 359~ 360,
lidocaine, See Lid ocaine
maUetine,36O,
phenytoin, s.., Ph enytoin
pro<:ainamide, s.., Procainamide
propafenone,360,
quinidine gluconate, 360,
quinidine mlfate, 360,
fordysrhythmias, 3581, 359. 359" 360,
.. local anesthetics, s.., l.ocAI. ANlSlHEllO
sodium chlorid e (N.O ), 439t
action. and u ..... 439,
administration alert., 439,
adycrse dIed" 439t
intera<tion',439t
LibraryPirate
ions,H6t
pbarmacokinetics, 439,
sodium Iryaluronate, 741
sodium hydroxide, 242
sodium iodide- 131, s.., Radioaaive iodine
sodium ion channds. 358, 358/
sodium ,tibogluconate, 521,
Solarau. s.., Didofenac
Solarcaine, See Benzocaine
Solu-M.droL s.., Methylprednisolone
Soma, St, Carisoprodol
Soman , 121,
somatic nervom systrm, 127- 28
somatic pain, 219
somatostatin, 660
somatotropin,659,659,
Somavel!. Set Prgvisomant
Somin"", See Diph enhydr-dffiine
Somoeri ph~nom~non,
Sonata, Stx Zaleplon
""rafenib, 563t, 564
~1\1
905
"""
imipramine, IS7t
medroxyprogc'trrone ac~ate, 706,
morphine sulfdte, 223 ,
phenelzine, 190,
senraline,188,
.umatriptan, 234,
zid<wudin. , ,31,
standardization,97t
uses, 961
stable angina. 340, S.. alsc Angina
!""""';.
S",p/tyk>axru5 ~wreu"
di ....... , caused by, 480t
methkUlin- r.. istant, 481, 498
tesiSlanU' to ~nkiUin, 4791, 481
skin infection,. 752
StarliL Sa Nateglinide
STAT order, 20
STAnN. (HMG-CoA REDuC1l'.,';l;
INll!l!ITOlS):
administration, 288
adY.""dfects, 287t, 288
coenzyme Q I0 and, 290,
drug. dassifii a,
atorva'tatin, s.., Aton....t.tin
Huvastatin,2871
lon'tatin, 20~ 287,
pra'''statin, 287t
roSllva'tatin, 287,
.inwa".!in, 20" 287t
mechanism. of a<:tion, 287-83, 2S9/
NUr>ing Proce.. Focu~ 292--94,
pharmacotherapy with, 287-83
.... , ... a .. hma,ku., 592
'talU5 rpUrptirus, 16St, 169" 171
,tavudine, 530,
steatorrhea. 635
Stdazine, s.,., Trifluoperazine
stem aU, 390, 390/
St emrtU, Sa Proch lorpernzi ne
steroid .. 283, 284/
sterol nudeus, 283
Strvens---john""n syndrome, 1St
StUbostroL s.., Diethylstilbostrol
Stirnate, &e Dcsmop~in
stimulants, central ncrmu ystem:
a mph.tamin .., s.,., Amphetamine,
caffein., 81" III
cocaine, See Cocaine
methylphonidate, See Meth ylph enid ate
stoma<:h, 608, 608/, See a/so Upper
gastroint.stinal tract
Strat<gic National StockpU. (SNS), 118
906
Index
Stran~ra.
&. AlomORlin~
75-0
cornrnm. 750
granulmum. 750
luddum. 750
spinosum. 750
Srreprococcu" 480,. 752
StreptococCI" p<"lellmOM;"'. 479,. 499
S"l1U'P"lQ(; RAMlNS. 494
quinupri.tin/dalfopristin. 494. 4951
stJqltokina",.383,
stJqltomydn. 489. 490,. SOO,
stJqltozocin.555,
Striant. 7181.
T.. to't~ro ne
strou mlum<.198. 298/. 299/
Slrom~ctol Su [vermectin
stratum
stratum
stralum
stralum
stratum
basal~.
Su,,"o
"'
Su Etho. uximide
~thosuximide.
m~thsu.ximide.174'
ph.nsuximid 174,
mechani,ms of action. ] 74
pharmacolherapywilh, 175
sucdnykholin~. 2531
actions and u", 253,
administration alert .. 25 3,
ad,..,,,,, dfccts, 2521. 253~ 278
interaction .. 253,
overdo", tn:atment. 253 ,
pharmacokinetics. 253,
sucralfale. 616
Sudafl. Su P.. udoophedrine
LibraryPirate
""0
T
T uU .. 45O
tablets:
administration guidelines, 22. 23,
cru.hing. 22
IYP"" 22
Tabun. 121,
tacrine. 140. 1401. 264. 264,
tacrolimus:
ad.,..,r.. cl'fects. 458,
forderm.liti .. 761
as immunosuppr.... nt. 457. 458,
mT p_""ri._,i . 7';1
tadalafd. 722. 722,
Tagamet. Se~ Cimetidine
Talwin. Su Pentazocine hjdrochloride
Thmbocor. Sec Flrcainide
Thmillu. Sa O",ltamivir
tamOIifen.5621
actions and u ..... 5621
administration alals. 562,
ad.,..,r.. effects. 561,. 5621
interactions. 562,
pharmacok.in.tic 562,
for spo<ifk condition,
brrast can=. 560--61. 561,
mal. inferlmty. 7 18
Index
TR!acuc ANI1~
LibraryPirate
907
hydrochlorothiazide. See
Hrdroc: h lorothi az id~
indapamide, 303t, 422.
methydothiazide, 303~ 4221
metolarone, 303" 422,
mechanisms of action. 420, 421[
for 'prdfic condition.
heart faUure, 328" 329
h)'l.'tnemion, 302~ J.O.l--4, JOJ,
rtnal failurt, 422- 23, 422,
TIlIAZOLINEDlONE5:
adve""dfe,ts, 687t
,haracteristic&' 688
drugs classified as
pioglitawne,6871
rosiglitazone,6871
rout~ and adult doses, 6871
thioguanin . 555" 556[
thior~ntal , 2511
actions and uses, 251.
administration alens, 251.
.dve""effect .. 2511
intera.r:tion .. 251,
OYerd05e treatment, 251,
pharmacokinetics, 251 I
ThiopkL Sa Thiot."a
thioridazin., 206, 206t
thiotepa, 555,
thiothixen. , 209.
Thorazine. See Chlorpromazin e
thrtt ch<-cksof drug administration. ]9
thrombin. 370
thrombin time, 372.
thrombocyto~nia, 372
thrombocytopoie.is,394
thromboernbo.lk disordtrs., 37]
TIlIOMBOLTIlCS:
definition, 373
drugs classified as
alt."la .... See Alt~rla.e
rtt."la ... Su ikt."lase
strtptokina..,383t
tenccr."la .., 383~ 386
mechanisms of action, 373, 3731, 383
Nursing i'ro<.... Focu.
....... m.nt,384'
...;oluation of outcomecrit<Tia, 385t
implementation
interv.ntions and rationale..
384--f15,
patient and famUy education,
384--&5.
planning: patient goals and expected
outcome .. 384,
potenlial nursing diagno .... 384,
pharrnacotherapywith,348-49,
383,386
thrombopoietin, 397
thrombu., 37]
Thyro- Bkxk. Sa Potassium iodide
Thyrogen. See Thyrotropin
TIIYJ.OID AGINI"S:
90 8
Index
THYJ.OIDAG~
(",MI.)
drugs classified as
deskcatrd thyroid. 663. 6641
lrvothyroxine. Su Ln"Olhyroxinr
liothyroninr. 663. 6631
liotri", 6631
NU,"ing Process Focus
as ..ssment.6681
.valuation of outcome critrria. 6691
implfmr ntation
interwntion. and rationales. 668--691
pat""t and family rdocation. 668--691
planning: patimt goals and expected
outcome .. 668,
polential nursing diagnooe .. 6681
pharmacotherapy with. 662-{i3
thyroid gland:
in cakium metabolism. nlf
disordrrs.659~ 6621. SN:~lso
Hyperlhyroidism; Hypothyroidism
functions. 662. 662f
thyroid storm. 664
Thyroid USP. Sa ~skcatrd thyroid
thyroid-stimulating hormone (TSH ).
6581, 660.
Thyrolar. See Liotrix
ThyroSafe. See Polassium iodide
thyrotropin. 6581, 6601
thyroxine. 662
thyroxine -binding globulin (TIlG ). 662
tia~bin . 1691. l71,
Tiamate. Se~ Diltiaum
Tiazae. Sa Diltiazem
Ticor. See TIeardUin
tkaremin.4841
Tic. See Haemus Calmen.-Gu~rin (BCG)
vaccine
Tidid. See Tidopidine
tidopidin 349. 379,. 380
tigtcydine. 488,. 4g9
Tikosyn. See Dofetilid.
Tilad. See Nedocrornil .'lOdium
tiludronate. 7391
Timentin. 4g5
Timolide. 302t
limo!ol. n it
actions and
1361. 771,
administration alrrt .. 7711
adv..... dfrct .. 315 343~ 771,
inleraclions, 7711
pharmacokinetics, 771,
for .~dfic condition.
angina and m)UC3rdial infarction. 3431
glaucoma. 769. 7701
hyprrtfn,ion. 3151
migrain 2331
Tirnoptk. See Timo !ol
Tinactin. See Tolnafiate
tinetur 98,
Tindamax. Sa Tinidazole
tin.a capitis. 507,. 752
tinea crun . 5071. 514. 752
tinra redi .. 507,. 514. 752
U""'.
LibraryPirate
IndH
",
(TCA,):
adv.... effect"~ 155t. 156, ]861
contraindications, 156
11lICYCUCANfIDEPI!ESSANTS
LibraryPirate
drugs classiflla,
amitriptylin . Su Amitriptyline
am=pine,I86,
do,"ipraminc, 155/
desipramine. ]55~ 186,. 200
dOl"'pin, 155,. ]86t
im\>ramine. Me Imipr-dmine
ma;>rotiline. 186,
nottriptylinc, 155" 186,
protriptyline, 186t
triJ:lipramine.I861
h ..b-drug intrractions, 100,
"",chinisms of action, 184, 1&5[
Nursbg Proce.. Focus. See
Antidrp",,,ants, Nursing Proct>S
"""'
drugs classifled a,
a1rr.otriptan,23).
detriptan.233,
fro;"3triptan,23),
naratriptan,2331
rizariptan,233.
sumatriptan. S.. Sum . triptan
zolmitriptan,23),
NUr.lbg Process Focus
...."mem, 2351
909
impl<mentaoon
evaluation of outcome,riteria, 236t
interventions and rational.s,
235- 36,
pati.nt and famUy Iucation,
235- 361
trl'P"nosomiasis, 521t
TSH (thyroid-,timulatinghormone),
658 660t
TSPA. Stx Thiotrpa
tub< f..-ding. See Enteral nutrition
tubc:rdes,499
tuberculo,is, 116.
inddence, 499
pharmacothrraPr, 499, 501. Set al,.,
AN"rmJII.ICULOS1S DRUG>
tyramine:
deflnition,189
food, containing, 189,
MAOls and, 156. 189
Tysabri. Set Natalizumab
Tyuka. Stx Telbivudine
Tyzine. Stx Tetrahydrozoline
U
ulcer, 60
ulcerath.., colitis, 621 " 625
Ultan . Stx ~tlurane
Uhiva. Set R<mifenlanU hydrochloride
Ultram. Se.Tramadol
910
Index
urinaly.is, 418
urinaryt""'t inkction ( UTI ):
ba<uria causing, 480,
incidence, 479,
natural tkrapywith cranbury. 42S,
urine,418
Urodde. See Hydrochlorothi azide
urofoUitropin.712t
Uro- KP neutral. See Potassium and sodium
phosphates
Uroxatral. Sn Alfu,min
urticaria,577
U.S. Depanmrnt of H....Jth and Human
S.rvices,6f
U.S.drupctt.dules, 14, lSI
U.S. PhamtfICcpocW (USP ):
histcry. 4-5.6f
medkation error ll'porting sl"tf1ll. 91
U.S. PMrmfIC<>poeia-N"tioM/liJrmulllry
(USP-NF ). 5, 6f
I JSP I,h<-I. ~. 'if
uterus:
dysfunclional bleeding. Se~
Dysfunctional uterine blding
rdaxant . See TOCOLYTICS
stimulants. See 0xrr0cJcs
v
vaccination, 448. See a!so Vaccine.
vaccines:
administration, 448--45O
ad,.... dfects, 450
anthrax, 119
cultural influ<uce. on administralion,
451t
LibraryPirate
definition, 448
diphtheria. tetanus, and ponu"i . 452t
haemophilus type Bconjugate, 452t
hrpatiti.A.452t
hrpatitis B. Sn Hrpatili s B vaccine
human papillomavirus,452,
influenza, 452t. 540
mea>!e., mumps, and rubodla, 452,
pnrumoco<ul. 452t
poliovirus, 452t
public tt.alth dfe<ts. 447 t
rotavirus, 452t
schiules and ages, 452t
smallpox, 120
type 449
varicdla zoster/chickn pox, 452,
vaginal drug ~dminimJtion. 26t. 27, 28f
Vagi stat. Sn Tioconarole
valacydoYir.538,
"'ldecoxib, 470
Valergen. See Estradiol ",lerate
",lerian:
drug interactions
Joraupam, ] 58,
morphine sulfuu. 223t
ovrrvifW. 1001
ptt.nobarbilal. 172,
risp"ridone, 2] 2t
thiopental, 251,
u ..s,96t.153,
Vakri<>na officiMu.. Se Valerian
Valium. See Diazopam
vaJprok!lcid (dh-alproa sodium), 176,
action. and u .... 176t
administration alerts, 176t
adverse effts, 160t, 173,. 176,. 194,
interactions,176t
owrdo.. treatllXnt. ]76,
pharmacokinetics, 176t
route and adult do ... 160/, 194,
for sp"dtlC conditions
anxiety. 16(1,
bipolar disorder. 193. 194,
migraine. 233,
"UUll", 169" 173, 173,
",l""rtan, 31 It. 327
Valtrcx, S<Y Valacyclovir
Vanrodn. See Vancomycin
v.nmmydn . 4<j~t. 499
",ncomycin-re.istant enterococd
(VRE),481
Vam .... Se< Histrelin
V.... QTA. See HepatitisA vae<:ine
Yardenafi~ 722. 722,
",rkella.752
",rkella vaccine. 452,
",rkdlazoster virus, 539
VarivaL Sn Varicdla ...a:ine
Va"",r. Sn Ikpridil
V.... K1k,302'
W.soaJNSTItlCfOlS!W.>oPItF..I>01tS, 408
vrnlilation,590-91
Ventolin. See Albuterol
""ntricular fibrillation, 355,
vtnuicula r fluner,3551
""ntricular tochycardia. 355,
vrntrogluteal .ite, 31
Veramyst. Se< Flulicaso ne
'''''''d pamil,3661
aCiions and u ..., 366t
administration al .. ts, 3661
advrrse dfe<t., 233~ 307t. J.O/
J60t. 366t
int eraction . 366,
mechanism. of action. 307
Indn
o""rdo .. treatm~nI, 366.
phamlarokinetks, 366t
for 5ptCifk condition.
angina and nI)'>GIrdial infar<tion, 343.
dysrhythmia., 358 359~ 360,. >65
hy~rtemion. J07t
migraine. 233,
Ver.lan. Me Verapamil
Yrrmox. Sre Mcbt nddwk
V.... d. Me Midazolam
v<rtigo.577
verylow.<f.nsity lipoprotein (VLDL).
283.285/
ve.icanls.553
vrend. Me VorkoDa7.0I.
Viadur. Me Uuprolid.
Viagra. Su Sild~nafll
Vibramydn. Su Doxycydine
Vkodin.222
Vida. Me Didanooine
viUi.607
vinblastine. 5sw, 559. 559,
VINCA AUAWID>:
,pedftt:v;r1I5I"'
vi"",ral pain. 219
Viorulo ... Su M.thykellulo..
Vi,in . S<"C Tetrahydr07.Olin~
Vi,ine LR. Su Oxym<lazoli".
Visk~n. S. Pindolol
Vistari!. Se. Hydroxyzine
Vistid~. S. Cidofovir
visual impairments, 74t
Vita-C. Se~ Vitamin C
LibraryPirate
vitamin(.):
characteristics. 639
classification, 639
ddki.ndes.641J-.41, 640t
<XU>$, 640
functions.640t
lipid- solubl~
characteristics, 639
vitamin A. SIT VitlJUin A
vitamin D. Su Vitamin D
vitamin E. S<"C Vitamin E
vitamin K. Su Vitamin K
Nursing Process Focus
a .... "m.nt.645.
evaluation of outcom. criteria. 646,
impl.mentation
intrr""ntions and r.ltional~s,
645--46,
pati.nt and family education,
645--46.
planning: patient goals and expted
O\Itrorn~s. 645t
pot~ntial nursing diagno .... 645.
rDmm~nded dietary aU"".. ncc-s, 640r
.\1Ipplements, 639,
water- soluble
characteristic 639
vitamin B,. s.. Vitamin B,
vitamin 8,. s.. Vitamin 8,
vitamin B,. Sec Vitamin B,
,;tamin B,. s.. Vitamin B,
vitamin Bo. Se. Folk addlfolate
vitamin B". Su Vitamin B"
vitamin C. Sa Vitamin C
vitamin A. 642,
characteristics, 641
ddki.ncy. 640.
functions. MO.
pharmacoth.rapy with
actions and uses.64I. 642t
administration alert., 6.012t
ad""r.. dfts.64I~ 642t
interactions.642.
route and adult do ... 64I'
rDmm~nded dietary aUowan",. 64(),
sources. 641
vitamin B complex. 64().
vitamin B,:
defid.ncy. 640., 643
functions. 640,
pharmaroth.rapy With. 643. 643t
rDmm.nded didary aU"".. n",. 64()t
sources. 643
vitamin 8,:
defid.ncy. 640., 643
function 640.
for migraine prophylaxis. 233,
pharmaroth.rapy With. 643. 643t
rDmm.nded dietary aUowan",. 64()t
sources. 643
vitamin B, (niadn):
defid.ncy. 640., 643
hrnctions.640.
9 11
for h)1l'<rlipid.mia
adver .. effects. 287t, 290
m~chani.msof action, 289/
pham13cotherapy with. 290--91
rout~ and adult dose. 287t
pharmacotherapy with, 643. 643.
recommended dietary aUow,IOec:. 640,
source',643
vitamin B, (pantothc:nk acid).640r
vitamin B. :
d.ficiency. 390~ 640t. 644
function 64(),. 644
pharmacoth<Tapy With. 643., 644
lecommendcd dietary aUowanec:. 640.
vitamin B,.. See Foli< .ddJfol . t~
vitamin B" (.-yanorobalamin l.400r
dtficifncy. 3901. 398. 640., 641
fun<tion . 64()t. 644
H, -re"'ptor blockers and. 61 4t
metabolism. 398--99. 399/
pharmacotherapy with
a<lion. and u .... 400.
administration al.rts. 400.
adver ...ffts. 398~ 400., 643,
interactiom. 400,
route and adult do ... 398t. 643.
recommended dietary aUowanec:. 640,
source 644
vitominC:
d.ficiency. 64()~ 644
a,dietary supplem.nt. 100.
function 64(),. 644
phamIacotherapy with. 643., 6M
recommended di.tary allowan",. 640,
vita min D:
daily "'qui",ments, 733
d~ficiency. 640.
dia~le. risk and. 6421
functions. 64()t
pharmacotherapy with. 641 . 641.
caldtriol. SNeakitriol
cholakif.rol.73.(,
dihydrotachysterol. 734.
doxercakiferol. 734,
ergocakiferol, 734,
paricaldtol.734,
rommended dietary aU"",.. nec:. 64(),
sourcc:,.641
synthesi . 732. 732/
vitamin E:
deficiency. 64O~ 641
functions. 64(),
pharmacotherapy with. 641. 641.
romm.nded dietary aUowanec:. 640.
sources.641
vitamin K:
d~ficiency.64O . 642
functions. 640,
pharmacotherapy with. 641., 642
recommended dietary aUowanco. 640.
sourcc:s.642
a. warfarin antidote. ID.
Vita- Plus E. S. Vitamin E
912
Index
Vivactil. Sn Protripl)lin~
Vivdl . Se. E.tradiol
VimnaT.E.N.,651
VLDL (""ry low-den.itylipoproteinl,
283,28S!
""latile inhalant .. abus<, 10&
Voltarm. See Uidofenac
",miting, 625. Sn ~lso Antiemotks
""miting cmter,628
""n Willdmond', di~s<, 371., 372- 73
""rioonazol. ,5l3.
""rinostat, 563.
VoSoI. See Acetic acid and hydroconisone
VoSpire. See Albuterol
VX,I2I.
Vytorin,292
Xenkal. Se~Orli'tat
Xopen.L Sa Uvalbuterol
Xy!ocaine. See Lid ocain.
Xy!ocard. Sn Lid"". i".
xylom.talOline, 581.
Xyzal. See u,..otirizine
y
Yasmin, 698,
yeast., >07
Yodoxin. Se~ lodoquinol
yohiml>e,223.
young adulthood, 72
Yutopar. Sn Ritodrine
Z
zlfirlukl~I,601t
W
warfarin, 3761
action, and ~', 3761
administration alert.. 376,
ad .... ""'dfect.. 374" 3761
distribution , 39
genetic polymorphi'm' affecring
melabolism, SIr
imfracrion,
dietary supplemrnu, 57
drug, 39
herbal tb.rapie., lOO~ 376,
oral comra"'pti ...... 699
overdos< trealm.nt. 376.
pharmacokinetics, 3761
for specific conditions
after myocardial infarction, 349
thromboembolic diseas<, 374., 375
WBC (white blood co.]] counll,3491
Wekhol. s.. Coles<"dam
WeUbutrin. Sn Bupropion
W.U,m..,rin. See Lmoo""rin
whit. blood ",Ucount (WBC), 349.
whole blood,408,
whole -bo...,l irrigation, 122
whoopinSOJugh , ]]6,
WinRho SDF. See Rho(Dl immun~ globulin
withdrawal, 14, lOS
withdnwal.yndrom..{J l, 10>-6, 1061
Wl"'illin. Sa Penidllin G procain.
X
Xalatan. Sn !.alanof'm,1
Xanax. Se~ Alprazolam
LibraryPirate
"
Special Features
A VO ID IN G M EDICATION ERRORS
H OME
&
C OMMUNITY C ONSIDERATIONS
LibraryPirate
.~
Chapter3,p.19
Chapter 16, p. 184
Chapter 22, p. 291
Chapter 26, p. 365
Chapter 27, p. 380
Chapter3 1,p.442
Chapter 32, p. 457
Chapter 34, p. 489
Chapter 38, p. 582
Chapter 43, p. 659
Chapter 47, p. 740
.223
The New Fountain of Youth!, p. 275
LibraryPirate
PHARMFACTS
AlternativeThtrapies in America, p. 96
Anesthesia and Anesthetics, p. 242
Angina Pectoris. p. 340
ArWl'ty Dlsoroers, po 15 1
Arthrllis,p.741
Asthma, p. 59 1
Attention Dendt-Hyperactivity Disorder. po 196
Bacteria! Infections, p. "79
Cancer, p. 548
Chapter 45, p. 695
aolling Disorders, p. 371
Community He~Jth Sbtistic.s In the United States., p. 80
Consumer Spending on Prescription Drugs, p. 5
iJegenemtive Diseases of the Central Nervous System, p. 256
Diabetes Mellitus, p. 680
Dysrhythmtas. p. 355
EpiIrpsy. p. 168
F.:s:tentofDrogAbuse,p.I"
Ht.al Effecu Caused by Specific Drug Use During Pregnancy,
p.68
Fungal, Proloroan, and Helminthic DIsea5es, p. 507
Gastrolntl'Sllnal Disorders, p. 621